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1. That he/she has read all the prvvisiom ofibis sprficatioik and that the desmip im incbded mtbis application,am omect to the best of his/her <br /> kaowhvdge end <br /> 2. That he/she is the owner of the respective property,or is qualified to rgxw=l the owned and . <br /> 3. That he/she will assume fall raponAility far all FilbMW forpmouai iauuy ordamage to propedy W ichmay arise oat ofthe work dwmW above, <br /> or winch may arise oat ofWz&or Silage to do the warlcpcovided hmvk and <br /> 4. That in the event any claim o£sueh lidmili y is made agaiest tLeCoaudy of Sao Ao'aclim or arty dapwWwnf,offc iat err employee&MOty he shall <br /> defend,iudennffy and holdthem and each of timn barnAm for such clan;and <br /> 5. That work shall be pedormed by the applieatlt and/Of say representative of the applicant in the County Right-of-Way at the above indicated site <br /> wlth a valid Sea Joaquin.County Ea nadmeot.Permit,and <br /> 6. That if permission is granted as regmsted,he agneas to do the wade described inaeoo daaoe with alt turns,omdNom and rhea ofthis and any, <br /> a#Wied sheet included as gmsal of special Ill provisions. <br /> Date <br /> FLUM Il HECTOR COAUMM <br /> »»»»»»»»»»»»»»»»»»» <br /> t ENISIMqGCONDMONS«««««««««««««««««««« <br /> L DRftWAY: Now ❑ rat ❑ Gravel ❑ AggnagateBase ❑ Paved(pow) ❑ Psved(Good) ❑ <br /> 2. SLOPING: AwayframPay..A ❑ TowandaPavement ❑ Flat '❑ <br /> 3: YIPEB:. Nave ElS-Type <br /> Ofimpipes inadobadwod: Yes ❑ No ❑ Approaches 0 emu Drab p Size <br /> AftecLmeut to new6mls pipe: Yes ❑ No ❑ <br /> 4 HEADWALL: Yes .❑ No' ❑ <br /> & ASMALT CONCRETE DEM. Yes p No p <br /> G..BARREMS ak"R40-cMay <br /> Y. DITCH Yee ❑ No ❑ IfYem. V Style ❑ 2 Feint ❑ Other ❑ VrW& Depth <br /> »»»»»»»»»»»»»»»»»PERMTREQUIREMENT8<z«««««««««««««««e«««< <br /> 1.DRIVEWAY: SFR ❑. COULOPtCIAL ❑ AGRICULTURk ❑ INDUSTRIAL ❑ <br /> PAVED with «A&L Depth A.C,ever. "Adm.Depdr 3/4"AR <br /> Notes <br /> 2. YIPS& L of Pipe Regnirpd Ft.and Dimider of Pipe Inch <br /> To be000noctedtoany adjaoentdriveway*0 Yea 0.No p <br /> DRAIN"D f ET REQUIRED Yes ❑ No ❑ <br /> Todd (with Proposed) Tetd Number of Stumm Oaataa bdeft <br /> Notes <br /> 3. BEADWA.LL Yes ® No Q <br /> 4. PAVED FRONTAgE: PAVED with ��"Mn Depth AG over "h m.Depth 3/4"A.D. <br /> b�teasuriag Feet m teerg$r and Feet in widdi <br /> FEES <br /> Driveway Farnoaclimmat Permit base ties...........................$85.00 <br /> Field Inspection <br /> ❑Driveway m/or w/o pip&.._...__. _ .`..$95.00 ❑Paved 13 <br /> froatage.�.___._�.V_....$100.00+0.46/ <br /> ❑Driveway w/bos(5alvert__.._ _._ . _ __.Si55.00 ❑Cry,Gutter,Sidewalk..:.. ... .._5140.00+09&% <br /> Cmdal em p iter,c:lAaesaVpplioation.for PermilsUiyaway and Paved Frontage Pags.2 cf 2 RevLad 8/2000. <br />