Laserfiche WebLink
THE"F1A :A.V"1='tml jwm Y ,-unit imam mo: <br /> I. That he/she has read aR the provisions of this apgfication,and that the desmintien inchaled iatltis application we comd to the bast of bis/her <br /> kmwhvdge;and <br /> 2. That he/she is the owner ofthe respective property,or is qualifiedto rept'eewt Ore ownw,and <br /> 3. That he/she will assume fall ray far all fid ility forpersonai iujaryordamage to property whichmay arise at ofthe work descried above, <br /> or which may arise art ofhis&w&&no to do Ore wank provided herein;ami <br /> 4. That in the event any claim of sash tiabilify is made againt ihvCowr y oft=joagi ss or eery depaatnsenk official or employee gwrw ,he shall <br /> defend,indemnify and holdthrm and each oftanr harmless for suds claing and <br /> S. That work shalt be pedomned by the applicant and/or any representative of rho applicant in the CmAy Right of-Way at the aboveindicated site <br /> with a valid San Joaquin Cowry Eummcbmagmt Pemtit;and <br /> b. That if permission is as recited,he agrees to do the work described in a000rdaoce vA&all teens,oeodkkm and restriction oflhis and any, <br /> attached shed,' as general or pnial M <br /> Signatme,ofAAppficaet-Tilte Date <br /> FIELD INSPECTOR COAMENTS <br /> »»»»»»»»»»»»»»»»>}»»EXiSMIGCONDMON3«««««««««<a«««««««««« <br /> L DRAMWAY: Nape ❑ Dict Orm-I ❑ Aggregate Base ❑ P+v«Kp") ❑ Pave (0ood) ❑ <br /> 3.SLOPING: Avmyyfn�nm Pavement ❑ Towards aa Pavna t -ElFlat- <br /> 3:PIPES:. Nam �J� Eaig-Type <br /> Ofhar popes in ueigbborlsood Yes ❑ No Approaches ❑ Cross Drain ❑ Sire <br /> Attachment toaeighbor'sYes ❑ No <br /> A.HEADWALL- Yes ElNo <br /> S.AdSPR4LT CONCRETE DIKL►:' Yes ❑ No <br /> 6..BARRIERS ak"Right-c&Way <br /> 1. DrrCH Yes ❑ No IfYes:• V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»>>>>> »»»»»»»»»»PERMITREQU REMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR _ OOMMERCIAL ❑ AGRtCULTUR$ ❑ INDUSTRIAL ❑ <br /> PAVED with "?triter.Depth AC.over "Min.Depth 3/4"Aha. <br /> Now <br /> 2. PIPE& LengthofPipeRogairod: Ft.and DitmofeterofPipe Inch <br /> To be eooneded to my adjaca t driveway pipe Yes ❑ No AL <br /> DRAINAi3E INIET REQUIRED Yea ❑ No <br /> Total T.909th: (with proposed) Total Number of Stem Dnk fialds <br /> Nies <br /> 3. EM&DWALL Yes ® No . <br /> d PAVED FRONTACvE: PAVED with "Mm.Depth AC.over "Mia Depth 3/4"AB <br /> kieasuring Feet in kngih and Feet in width <br /> ]FEESDriveway Facroadnne®t Permit base flee_........................ 585. <br /> Fieldlnapection <br /> V�rivawayw/or w/opipa......._ .._ .._ _ __.._ `SSS ❑Pavadliootaga _ _ _ sI0000+0.46/& <br /> ❑Drivewayw/box Cnlveat._._ _.. _.$155.00 ❑Curb,ataw,Sidewalk.......................$100.00+0.98/& <br /> CoanterlCa WlUter,c:lAoce sVVpfiw ion for PermiWl)riwway and Paved Fnontap Page.2 of 2 Revised 812000 <br /> .ia <br /> i <br />