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I. 11W he/she has read all the provisions of this qTfi,,fL01%and that the description immchmded mthis application,airs correct to the best of his/her <br /> knowlwdge;and � - <br /> 2. That he/she is the owner of the respective propemty,or is qualified to represent the owl and ~ <br /> 3..That he/she will assume fall responsibility for all tiabiiLy Arpxsonal*uryor damage to <br /> or which may arise oat of his/her taiium to do the work provided herein, Pam 'wh may arise out ofdme work described above, <br /> and <br /> 4. That in the event any claim of such liability,made against t&eCounty of San Jbagiun or aaydalwUment,offal ar employee thereog he shall <br /> defend,mdetnoify and hold*=and eacih of them harmless for such claim;and <br /> S. That work shall be perfmmed by the applicant and/or any reprGveutItiye of the applicant in the County Ri*-of-way at the above indicated alta <br /> with a valid San Joaquin County Ewoad,ent p�and <br /> 6. That if permission is granted as regaested,�agrees to do the work described in <br /> attached d=4' es genal or> at acdaaoe witlm ,° �and restriction ' and any <br /> b� <br /> Signature of Applicami.Titte <br /> Date <br /> FIELD 1NSPEC OR c0 3VW NTS <br /> »»»»»»»»»»»»»»»»»»»»FX[ST NG <br /> } CONDIITONS«««««««««««««««««««« <br /> L DRIVEWAY: Nage ❑ out cimvol ❑ Aggrag#eBase ❑ Paved(i w) ❑ Pa <br /> 2. SLOPING: Aanyfnom Paves Towards P:vmrmta ) <br /> ❑ Flat ❑ <br /> 3: PIFES:. Now Existing-Type <br /> OdwPiPes <br /> m orhDo& Yea ❑ No Approaches 0 Cross Drain ❑ SizeAftadmuot �] <br /> to neW&OAYes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S.ASPSALT CONCFXrE DM. ee ❑ No <br /> 6..7ltARR1 M alongRight-of Way <br /> 7. DITCH Yeas ❑ No IfYes: V <br /> style ❑ 2 Poi ❑ OMI>w ❑ Wrdth � <br /> »»»»»»»»»»»»»»»»»»PE tWT RE <br /> v� QUIItEMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGWCULTETit�; ❑ INDUSTRIAL <br /> PAVED with Z— " ❑ <br /> Mm Depth A C over "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Lane (If Pipe Re. Ft and Diammia6er a&pipe Inch <br /> To 6e connected to any adjacent driveway pipe <br /> yes ❑ NO <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Totr{1 <br /> Nates (Willproposed) Total Number of Storm Drak Islets <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with " <br /> Mm.Depth AC.over "Mrs Dop&3/4"AB <br /> Meng Fejt in length and Feet in width <br /> ------------ <br /> Driveway End p <br /> amrt base fee .. FEES <br /> ................ ......... 83. <br /> geld Inspection <br /> V-6--ay w/or w/o pips......... :...._.._.._.:.__. <br /> _._. ❑ <br /> E-1Paved Driveway w/Iwx Culvert._...... ..........I..._._. Pfi0 -_ $100.00+fl.46/ft <br /> ❑Curb,Gutta;Sidewalk......................$100.00+0.98/8 <br /> vmterlCampatat c:lAccessWppIicWon for PermitslDriyeway and Paved Fror4age p <br /> age.2 of2 Revised 8/2000 <br /> i <br /> ;r <br />