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inn,ACrLil.H1\1 tal.itLD x l.Ei(l l@ LLL: <br /> T. That heoAe hes read alt the provisions of this appy,and that the dascaiption iuchsded intbia moa ate comer#to the best of his/her - <br /> kmwlwdge,and - <br /> 2. That he/she is the owner of the respective propedy,or is qualified to represent the owner;and <br /> 3..That he/she will assume&H responsibility for all liability f3orpecaonat u jury ordamage to property which may arise out ofthe work described above, <br /> or which may arise out of his/her hihue to do the work provided and <br /> 4. That in the event any claim of such liability is made against tbeCounty of Sim Aoatom or any departmeit,offidd or employee thereat he shall <br /> defend,kdemnffy and}m-U%m and each ofthem batmlesafor such claim;and <br /> 5. That work shall be perf rmed by the applicant and/or say representative of the applicant in the County RighGof way at the above indicated site <br /> with a valid San Joaquin Candy Encroad moot Permit and <br /> b. Tbat if pumission is granted as requested,he apm to do the work described in accordance wi h all terms,000dr ons and restriction of this and any <br /> induded as oras <br /> S4p&tme ofAppficaat-Title nate <br /> FIELD INSPECTOR COhfl4U T!'S <br /> »»»»»»»»»»»»»»»»»}»»EMSTMO CONDITIONS««««««««««««««t«««««< <br /> L DRIVEWAY: Now Qict ❑ Gravel ❑ Aggregate Base ❑ Pa ) ❑ Paved(Good) ❑ <br /> Z SLOPING: A y Pavement ❑ Towards Pavement ❑ Flat <br /> 3. FIPES:. Now Eaisti -Type <br /> Other pipes ianeighbad & Yes ❑ No Approaches ❑ Crow Drain ❑ Sipe —J <br /> Atfadtinent to neighbor' Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPEMLT CONCRETED , Yes ❑ No `1 <br /> f~.EARRHMS atougRW t-c&Way <br /> 7. DITCH Yes ❑ No IfYes: V Style ❑ 2 Point ❑ Other ❑ W-W& <br /> PERMTREQUMEMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with ?— "Mm.Depth AC.over �- "M M.Depth 3/4"A.& <br /> Notes <br /> L PIPES: Length of Pipe Rertnu'od: Pt.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑.No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total LeDgt.• (with proposed) Total Number of Storer Drate Batts <br /> Nates <br /> 3. EMADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "hfim Depth AC.over "Mia.Depth 3/4"A.B. <br /> Measuring Feet in tengo and Fed in width <br /> FEES <br /> Driveway Fnauachmart Permit base fee.....................t5.00 <br /> field Inspection <br /> away w/or w/o pips.. ..... .. _..❑Drivewayw/boxCulveR._._.._ ...... .... ❑curb,Gutta;Sidewa&.........—.._.....$loo.00+o98/R <br /> CauntalComputer,c:lAcceaslApplication for PermitslDriyeway and Paved Frontage Pags.2 of 2 Revised 8/2000 <br />