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1. -11W fWarte ncs reaa au the provWons of ups apphcatioq and that the descriptiam included iatbis application are coned to the best of his/her <br /> knowlwdgr and <br /> 2. That he/she is the ownrx of the respective propedy,or is cptalified to Mxcsmit the owner;and <br /> 3. That heAdw will assume fall oily for all tiabiky forpexsauai injuryor damage to property whichin"arise out ofthe wodc described above, <br /> or whichmay arise out ofhbAtw faihueto do the we&praMedherein;and _ <br /> 4. That in the event any claim of such liability is made againk thoCamly of Sam Jbsgim or any depertmwt,official ar employee tbm4 he shall <br /> defend,kdm*and hold*=and each of&m MmAess for sack eIsim;and <br /> S. That work&all be pafomed by the applicant and/or any representative of the applicant in the Cmaty Right-of-Way at the above indicated site <br /> with a valid San Joaquin CandyEamoadmnt and <br /> 6. That if peanission is as he do the work amocdance with all teens,eoadiiions and tnshiction of this and any <br /> attached sheat, <br /> of Title Data&& <br /> FIELD INSPECTOR COMMENTS <br /> ENTS <br /> EMSTRqGCONDMOM <br /> L DRIVEWAY: Now ❑ Dict Oravd ❑ Aggregate Base ❑ Paved(poor) ❑ Paval(Good) ❑ <br /> S. SLOPING: A fmm Pavement ❑ Towards Pavameot -❑ Flat <br /> 3. PRES.. Name- Exiding-Type <br /> Otherpipes inne101bodu d: Yes ❑ No Approaches 0 Cass Drain ❑ Size <br /> Attacbmeat to neW6aes pipe: Yeas ❑ No i <br /> 4. HL&DWALL. Yes ❑ No' <br /> L 1LsrmLT coNCRETL Dna. Yes ❑ No <br /> 6..BARRIERS along Erght oMay <br /> 1. DITC 1 Yes ❑ No IfYes:• V Style ❑ 2 P+oiot ❑ odw ❑ mwih Depth <br /> ?»»»»»»»»»»»»»»»»»»>PERIAITREQUIREIIBNTS<z««««««««««««««««««« <br /> I.DRIVEWAY: SFR COMMERCIAL [] AGRtCMTEAtt; Q INDUSTRL4kL .❑ <br /> PAVED with Mm.Depth A.C.over. <br /> Dept 3/4"A B <br /> Notes <br /> 2. PUM& L n8*0fPipaRegairoch Ft.and Dia>"W cf Pipe inch <br /> To be eoonected to any adjaaet driveway pipe Yes ❑JJNo <br /> DRAINAM INLET REQUIRED Yes ❑ No ld� <br /> Totel lmgk (withprvpoeed) Tutsi Na WkrofStaumOrntaInlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mao.Depth A.C.over "Mia.Depth 3/4"A.B. <br /> Measuring Feet in length and Feeat in widdi <br /> FEES <br /> Driveway Fhauschmemt Pemnit base fee...................... <br /> Held Inspection <br /> y w/or w/o pipe......... .. _ $93 ❑Paved fmtiga.._..._.....—.___.$100.00+0.46/$ <br /> Drivenvay w/box( ivat_ _...__. _.. _. 53.00 ❑Cnttb,Cutter,SmawalL.. __. SI00.00+0.99/ft <br /> CaunterlCAmprzter cAAcceu\Appliaatioa for PamitslDii eway and Paved Frontage Page.2.of 2 Revised 8/2000, <br />