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"i'HZ AYYLiI,B.L"t nDnr+n x '-Ksai.><.r sad that ih*des inchsdad iatloL4 mppli�tion are correct to the best of his/her <br /> 1. That halke has read all the provis►.s of this s cot' �° <br /> kwwtvvdge;and <br /> 2. That he/she is the Owers of the vespalive property,or es quafifiad to rapresaat the owner;and <br /> 3. That he/she will assamu full respamaiisRity far all tiabihity,farpecaooah iajmy ordamage to property whcch may arise out of the work described above, <br /> or which may arise out of his/her faih m to do the wank provided ,and <br /> 4. That iathe event any claim of aaechhiahility is made aga ind 1heCou dy of Sao Aoagim or any dam.a�tcesl°! '�ih shall <br /> defend,indemnify and hold*=and each of them huniess for such clam aesd <br /> S. That mark hall be paaf'onned by aPp <br /> the hil aand/or may reprexmts:tWe of the applicant in the COUWY Right-0f-Way at the above indicated site <br /> s <br /> with a valid Sera Joaquin COWLY E=OachmOd Pexm�snot <br /> ase agrees tai do O work dm nW is wwcdanoe ai&ad tears,conditions sad rest iction of this and any. <br /> 6. That if pamnis:sian is granted as requested, <br /> attached shot,mchtdad as general or Tecijd III Provisiom' <br /> Sigma ofApplicaat TMe <br /> FIELD INSPECTOR COMMKNTS <br /> L DRAEWAY: Now ❑ (travel ❑ Aggregate Base ElPa�(P ) ❑ Paval(aood) ❑ <br /> 12.SLOPING: Away Pavane TowudaPavanuat El FW El3. PIPES:. Nose /ESS-TYpe <br /> odmwpepm iamigbbodsood: Yes ❑ No Approaches Cross Drain ❑ Size <br /> Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S ASPHALT CONCRETE DIICE:; Yeas ❑ No 1►�l� <br /> 6..IlARRMS alongRWA-o&Way <br /> y. DITCH Yes ❑ No IfYes: V Style 2 Point ❑ Ohw ❑ WidW Depth <br /> L DRIVEWAY: SFR - COMMERCIAL ❑ A0RJ,--MTEJRt ❑ INDUSTRIAL ❑ <br /> PAVED with z— -"Mih.Depfh A.C.over, "Min.Depth 3/4"AB. <br /> Nates <br /> 2. PUMEk Length of Pip*Regairod:• Pt.and Dimm0mr of Pipe Inch <br /> Tobeooamdedtoanyadj c"t*hw'cypipe Yeas ❑,No <br /> DRAINAOE INLET REQUIRED Yes ❑ No UGJ/ <br /> Toht1 LmWh: (with Proper Total Nmaber of Stmmm Dredss bdefa <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "miiu.Depth 3/4"AB. <br /> Memoring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroach nud Pemb base fee_....:...:....._....... <br /> ..a/ a�yy <br /> Fe ldlmpection <br /> caws w/or w/o <br /> Y pepe.........._:__._._...._.........._..._. 5 ElPavedfiraats8e-._...._._..:»._.._»....S100.00+0.46/R <br /> ❑ Lkiveawayw/boxCulveut ._._ ........_. .............—$155-00 ❑C-NGut.W.S.Wewalk...........:...........$100.00+0.9ft <br /> CaurntexlCompister,c:1AccesakApplioatim for Pea W0fiyeway and Paved Finatago Page.2 cf 2 Revised 8/2000 <br /> :r <br /> t,� <br />