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1ii1%S'1J.s yav�r..a Y.r - <br /> I. Tbst hdgho has read all the provisions,of this and that the dmdpdm iwhWed inthis apphcxtion We wired to the best of i is/her <br /> km and K <br /> 2. That Itolshe is 1110 owner of the respective property,or is qualified to represart the owner,and <br /> 3. That hdghe will assume fall rtepcara�ily€err ail lia'bir forpasonai jury or damage to property which may arise out afthe work desonbed above, <br /> or which may arise out of his/her Eaihue to do the wank provided herein;and <br /> 4. That in the evert any claim of such liability is made against OwCotmty of San A mgiuu or asiy dam,afcia[or employee tbere4 be shall <br /> defend,mdetn*and holdihem end each at d m harmlesa for sash claim;sad <br /> 5. That work shall be performed by the applicantand/or any representative of the applicant in the Cmmly RW t-of-Vijay at tha above indicated site <br /> with a valid San Joaquin Coudy Faaoacbmeo t Permit;and <br /> b. That if is graded as rimed,he agrees do the wank described inacomhaace,vhh of turns,oonditicos and restriction cf Eris and any <br /> attached WK included 94oneral.or special III <br /> 3igneieueafApp} a6Titte Daus <br /> FIELD INSPECTOR COBOAR TS <br /> »»»»»»»»»»»»»»»»»»»EMSTtT OCONDITION3«««««««««««««««««««« <br /> t <br /> L DRAZWAY: Now ❑ Dia ❑ Gmv+el 0-) - Aggregate Base ❑ PvmkPow) ❑ Paved(Good) ❑ <br /> 12,SLOPING: Ai&yyrrfmm PAvemant ❑ Towards Pavoemod ❑ Flat <br /> 3: PIPES:. Nave -Type <br /> Od=pipw in orhood: Yes ❑ No ,tyl Approaches Goss Drain ❑ Sim <br /> Atta�rmeot to naighboee pipe Yes ❑ No <br /> 4.HEADWALL- Yes ❑ No' <br /> S ASPHALT CONCRETE DIKE:, Yea ❑ No, 16L <br /> 6..HARRIERS ak"Right-cMay <br /> 9. DITCH Yee ❑ No IfYes:• V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»»»»»»»»»»»»»»>PERLOTREQUiREMENTS<z««««««««««««««««««« <br /> L DRIVEWAY: SFR commmIAL ❑ AaRic-mTURk ❑ INDUSTRIAL ❑ <br /> PAVED with Z "11 m Depth Aa aver "m i,.Dep&3/4"A,B. <br /> Nates <br /> 2. PIPM I mR$of Pipe Resin- Ft and Diaad eter of Pipe inch <br /> To bevona ectod to any A. -out driveway pipe Yes .N <br /> DRAINAGE INIET REQUIRED Yes ❑ No <br /> ToW Length. (with proposed) Tohi N=Wkr of S6o=:Drdn ISaIe <br /> Notes <br /> 3. HEADWALL Yes n No <br /> 4. PAVED FRONTAGE: PAVEDwith "bfimL Depth AC.over "Mm.Depth 3/4"AR <br /> Measuring Fed in length and Fed in width <br /> FEES <br /> Driveway Fncroecbment Pamit base fee_.............._......t$95 <br /> Field Inspection <br /> japriv"yw/or w/o piper....._.. ❑Paved&c+atage _ _ ._x..__ 5100 00+0.46/ft <br /> ❑Driveway w/box calvaR._—._.._.......-...........-..---.$155.00 ❑curt,Clutter;smewanc_:.._......-.__...$100:00+0.98/ft <br /> CeantalCamputer,cAAcceselAPpiicatioa for Pamils\ikiyoway and Paved Froatage Pags.2 of 2 Rovis6d 8/2000 <br />