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-: 11�n,11i i stfa.rkt�i 11.1'.atf/J/a.,a.s.aaair aaJ�. - <br /> 1. That he/she has read all the provisions of this m(n,and that the deaden included ischia application are oo ct to the hast of 1risThea -� <br /> knowlwdge;and <br /> 2. That heldw is the owner of the respective property,or is Twified to represent&o owner;and <br /> 3. That he/she will assamo fait respo:sibiRy for ally faarpe mud 100y or damage to property which may arise out ofthe work desmbed above, <br /> or wfnchmsy arise out of hisAw f sihm to do the wortcptuveded herein;and <br /> 4. That is the event any claim af sach UAiMy h made against*eCamty of San JDaqianormydeparhaeuk official or employee theme he shall <br /> defend,indemuily and holdthem and each dthem bathe for such claims and <br /> S. That work shall be petfanued by the applicant and/or any representative ofthe applicant in the Courtly Right-of-Way at the above indicated site <br /> MM a valid San Joaquin Fauroadhmpat Pette erect <br /> 6. That if pen mon is as ho agues to do the wads dosarW in acoaAanca withall tonna,ooaditions and restrictionof this and any <br /> attache/shed,included or a,'e.CW l D <br /> Signetam cf Applicant-Title <br /> FIELD INSPEGROR C!OhBdR TB <br /> »»»»»»»»»»»>y»»»»»>}»»gXIgTM(} IQNS«««««««««««««««««««« <br /> L DRIVEWAY: None & Dirt ❑ Qnra d ❑ AwegteBaee ❑ Pavea(P-'w) ❑ PavftdcGood) ❑ <br /> 2. SLOPING: Aw fium Pavama t ❑ To"W&Pawamant ❑ Flat L� <br /> 3. PIPES:. Now En s ft-Type <br /> Olha'pipes ia=i0bodKxxk Yes ❑ No Approaches Cross Drain ❑ Sim -J <br /> Attachment to neighthoes pipe: Yes ❑ No <br /> 4.RF.ADVVAL .: Yea ❑ No . <br /> S.ASPEMLLT CONICRETL DIIfO.►r Yes a int~ <br /> C.RARREMS akkhgRigbUcf- <br /> 7. Dr1'CH Yea No IfYer, V St* ❑ 2 Point ❑ CJther ❑ Width Depth <br /> »> P rRIAITg <z««««««««««««««««««« <br /> L DRIVEWAY: SFR . COMMERCIAL ❑ At3RtCULTETR$ ❑ I1VDL]STRIAI. ❑ <br /> PAVED with �: ."Edm.Dep&A.G over. "Mm.Depth 3/4"A.B. <br /> Notts <br /> 2. PIPE& Lanb/bof Pipe Re"jm&• Ft.and Diauleter of Pipe bhcih <br /> To be 000necW to any adjaoeot driveway pdpc Yes �{.N <br /> DRAINAGE INLET REQUIRED Yes ❑ No 1�1 <br /> Tow Laos& (with proposed) Total Nu>abw of 86orm:Dedt h&ft <br /> 1Qatm . <br /> 3. HEADWALL Yea Q No <br /> 4. PAVED FRONTAGE: PAVED with ")ldia Depth A G over "Wm Depth 3/4"A.B. <br /> 1v[muring Feet in keg&and Feet in width <br /> FRES <br /> Driveway Fnaoacbmeat Permit base fee...........................W. <br /> Feld lnspeclion <br /> Drivawayw/or w/o ❑Pavodfinotage _ — ___.510000+8.46/& <br /> ❑Drivewayw/boxCalvat._................... _.. _ $1SS.00 ❑C utt,Gutter,Sidewalk...:... . ...--.-S-100.00+0.98/ft <br /> CountakCampuW,c.V=esslApplioation for PamitADriyaway and Paved Frontage Papa of 2 Revised 812000 <br />