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1. That he/she has read all the provisions of flus app and that the description inchsded iatt&M ication are correct to the best ofhisiher <br /> knowhvdge;and , <br /> 2. That he/she is the owner of the respective property,or is qualified to rpt the owned and <br /> 3..That he/she will assume fall city fix all liability fix personal injury or damage to property whichmay arise out ofthe woric described above, <br /> or which may arise out ofhis/her failure to do the wotic provided herein;and <br /> 4. That in the event any claim of such liability is made against tbecoody of Sart Aoagian or any deparbnen,official or employee thereof;he shall <br /> defend,iodemaTy and holdihens and each of them harmless far ands chug and <br /> S. That work shall be performed by the applicant and/or any mpresentatiVe of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin Coady Enavadmad Peadt;and <br /> 6. That if permission is graded as regiusted,Ise agrees to do tate wank desaihed in a000rdanoe vdrth all teams,oonditioos and restriction of this and any <br /> attached sheet,' as gmaai or special III <br /> /- SigoatafeofAppl=A-Titley Date <br /> FUMD INSPEL'I.OR COAffdW f'S <br /> »»»»»»»»»»»»»»»»»>}»»E)ONTtTi(3 CONDMONS«««««««««««««««««««« <br /> L DRIVEWAY: Now Dict ❑ Gravel ❑ Anragsla Baw Q Pave%x w) ❑ Paved(Oood) ❑ <br /> 2. SLOPINQ Away1rom Pavameot ❑ Towards Pavement ❑ Flat [� <br /> 3. PIPEW Now Eatatm' g-Type <br /> Other pipes inndoboefiood: Yes No�Approadns Cross Drain ❑ Size C� <br /> Attachme d to neighbor's pipe; Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S.AWEMLT CONCRETL I)n7- Yes ❑ No <br /> �.MARRMS ake;Right-e�way <br /> 1. WrCH Yea Z No ❑ If yes:• '11;. 2 Pbmt ❑ Other ❑ Wickh Depth <br /> ?»»»?»»»»»»»»»»»»»»»PERMIT REQLgREMElTS<z«««««««««««««««z«««< <br /> 1.DRLV&{OKAY: SFR COMLIERCIAL ❑ AGRtCULTUR19 ❑ INDUSTRIAL, ❑ <br /> PAVED with ."ltdm Depth A C.over 4— "Mm.Depth 3/4"AR <br /> Notes <br /> 2. PI MIk Lnngthompa ll-pirod:' Pt.and Diameter of Pipe inch <br /> To be connected to any adjacent driveway Pipe Yes /No <br /> DRAINAGE INLET REQUIRED Yes ❑ No I� <br /> Total (wi1h ProPM Total Naaaber of Store Dnin bdets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAgE: PAVED with "Mau.Depth A.C,over "Min.Depth 3/4"A.B. <br /> '"' �:iessunng Feet is leng&and <br /> Faet in width <br /> FEE'S <br /> Driveway Facroednment Permit base fee................ ..... ...5 <br /> FieldInspection <br /> "way w/or w/o pipe......... ..._ _.. S9i. ❑Paved 510040+0.46/ft <br /> froom...............__.._....._.... <br /> ❑Drivewayw/boxCulvat __. ._.. ....__.SiS5.40 ❑Corb,Clutter,Sidewalk..: _.. ..._.....5140.00+0.981& <br /> Couder\Compi ter,c:lAooesaMpplication far PamitsTk iyeway and Paved Frontage Page.2 c f 2 Revised 8/2000. <br />