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l• 1ffii IIa�sne nus roue art me provrsroffi offt is aPPYK3fiM and that dw description inchxled intbas <br /> kno � applicattiess are ex►aect to the bast of lrislher <br /> whwI2. Ila helshe is the owner of the respective property.or is cpraliffed to rpnmw gw owl and _ <br /> 3..That he/she will assume fall regwnsiity Sar all lyabt7ity for persan d*!Myo,damq,, to <br /> property whirlrmay arise out oftbe work described above, <br /> or which mayadse out ofhisofi r failure to do the wkprovidedhere®;and <br /> 4. That is the event any claim of each Hdxldy is made sgaiast lh&Cmuly of Sm hsAqm orany deparWwK afficid err °Y ea <br /> defmd,indemnify and holdthem and each of arum hanmlass fus ands claim;and � the�f;he shall <br /> S. That work shall be performed by dw applicant and/ar any repreamtafiW of the applicant in the Cormty Right-of-Way at the above indicated site <br /> wlth a valid San Joaquin County FAcroadunew Femd4 and <br /> b. That if pconission is granted as requested,he agrees to do the work described in a000rdluce with all teens,000d>kioos ad <br /> attacteshictica of this and any., <br /> bed <br /> An inchtdeej�s gmaYl��r a�ecral IIl <br /> N / Signat/ ofApplicaint-Title . <br /> . .Date <br /> FIELD INSPECTOR COAMWMM <br /> EXMTINc3 CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nme ❑ Da } Cnavrd <br /> ❑ AggnegateBas° i'aoed(Pw) ❑ Paved(Good) <br /> ❑ <br /> 2- SLOPING: AwaylivmPaaemed �Toww&Pavao> ❑ FutElPIPES:. Now ?NL, gig_Type <br /> m Yas ❑ No Approaches 0 Cores Drain ❑ 3ira <br /> Attubmeat to neWibor s pipe: Yes ❑ No <br /> 4. HEADWALL: Yea ❑ .No, <br /> S ASPHALT CONCRM DIKE: Yes ❑ Nes <br /> &BARRIERS aka$R4*-4Way <br /> 9. DXMH Yes ❑ No IfYes:• V <br /> Style ❑ 2 Heim ❑ Otlsrr ❑ Widtts <br /> >>�l>>>>>>.-�.>>>>>>>>>>>>>>>>>>>>»'>»»»PERMITRFQU U&MENTS«««««««««««««««««««« <br /> i.DRIVEVfrAY: SFR COMMERCIAL ❑ AGRkMTE M ❑ INDUSIRRIAL ❑ <br /> PAVED withepth AC over. "Mm.Dep6r 3/4"AB. <br /> Notes <br /> 2. PIPSSc L-wkofPipeR-74Md: FL and Dismdw of Pipe ince <br /> To be 0000ed+ad to any a4acmt Y pipe Yee; ❑ No <br /> DRAINAGE INF ET REQUIRED Yea ❑ No , <br /> Tatou Ieagth. (Wdh Pte) Tatal N=Wkr of Sl+orm Drain%jefa <br /> Notes <br /> 3. HEADWALLYes 0 No <br /> 4. PAVED FRONTAGE: PAVED with "Mm Depth AC over <br /> "Mm Depth 3/4"AB <br /> Meng Feet ns length and Feet in width <br /> Driveway Facmachmeat Permit base fee.......................... <br /> F FIi+ES <br /> �tton <br /> y w/err w/o pipe......._ .. _ „__ . _595.00 ❑Paved <br /> ElDrivewayw/bosCulvert._._. _. .... 8e--.__ _.__.,__._..$100.00+0.46M <br /> ._.- 5.00 ❑Curb,(fittay Sidewallc..:.._.............$100.00+0.98/ft <br /> CountalQMV, r,c:lAema kAppHcafion for PermhslDriveway and Paved For e2 of 2 <br /> �.. Revised=000 <br />