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1. LaLnmsanEw reap au uM WOMBS=or ants arm Mat ins <br /> lmowlwdgq and �aechaded iatbffi applicatios ate correctto the best of hislher ,.. . <br /> 2. That lielshe is the owner of the respective property,or is gwMad to represent Ste owrec,and <br /> 3..That he%he wM sesame full respaasibilily for an liabiily forpeisond m9mY or damage to property%hiehmay wise out ofthe work described above, <br /> or which may arise out ofhis/her failare to do the weaikprovided herein;and <br /> 4.That in the event any claim of such liab0ky is made againd ffieCoutty of San los(iLm or any dep u u ca%oficid or croployee fiereaC he shall <br /> defend,indeim and holdthem and each of the®hermleea for each claim;sad <br /> S. That work shall be performed by the apphcv*and/or nal,repmentative oft e,applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joagain County Facroadmeent Peuu&,and <br /> 6. That if psm issionis granted as a re age to do wak described in sooardaace with ail teens,eon and r+estactie <br /> attached sheet,is rti general or epecid M provis <br /> S41,-M eofAff icsat-TM& <br /> Dabs <br /> FIELD INSPECTOR COEDHIR,M <br /> »»»»»»»»»»»»»»»»»»»>E22S'iMOCONDMON3««<«««««««««««««««««< <br /> L DRIVEWAY: Nage ❑ Vitt ❑ Graven ❑ Aggregate aaw ❑ Paved(poar) ❑ Pavad(004 <br /> Z. SLOPING: Awayfrnm Pavement ACL-1 Towards Parmreat ❑ Fat ❑ <br /> 3: YIPES:. Now ❑ Existing-Type <br /> Otherphm intrei6bothood: Yes o Aplxoeches E Cross Digin ❑ Sim C� <br /> aunt to neighbor's 19Pe; Yea ❑ No <br /> 4.BIEADWAId.: Yea .❑ No <br /> S.ASPHALT CONCRM D=. Yes ❑ No , <br /> G.BARREMS atoogRight-o&Way <br /> 1. DrrCS Yes No ❑ EfYes:. V S1*41tx ❑ Other. ❑ WdBi Doh <br /> »>»>»»»»»»»»»»»»»»»>?»PBRIUTREQUIREIISNTS<e«««««««««««««««z«<z«< <br /> 1.DRl[VEWAY: SFR 4qtr� COMMML4L ❑ /tCMTVa ❑ INDUSTRIAL .El <br /> PAVED with Mm" Doh A C ower `T Mm.Dopar 3/4"A.B. <br /> Nates . <br /> 2. PUM I Ih of PiP° Ft.and Disndeser of Pipe filch <br /> To be conceded to any adjacentday pipe Yes po <br /> DRAINAGE MET REQUIRED Yes ❑ No <br /> Totd (wish proposed) Totd Number of Sborra:Drrdia bje& <br /> Notes <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAJqE: PAVED with "Mn,Depth AC.ova "hfim Depth 3/4"A.B. <br /> Fed in length and Feet in width _ <br /> FEES <br /> Driveway Earnoachment Permit base fee....................... .. <br /> 1=y <br /> tion <br /> w/or w/o pipe. _ ❑Paved fiaats$a _ __ 510000+0.46/ft <br /> ❑ <br /> Driveway w/box Gtirly ert. ._ SiS3.00 ❑Curk Gutter,Sidewallc.. . .. ... _...5100.00+o.q&* <br /> CauzaalComputer,CkAccesslApplieation for PennitalDriyawaynnd Paved Frontage Page.2 of 2 <br /> Revised W", <br />