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1. That he/she has read all the provisions of this app#iC2fiKn,and than the desc*ion included mil ob application are comact to the best of his/her <br /> knowkwdN and <br /> 2. That he/she is the owner of the respective property,or is gWifiedto represent dneowrna;and <br /> 3. That hedshe will assame full resportisibility for all fiabiltly fay peasonai injury or damage to property which may arise out ofthe work desmbed above, <br /> or which may arise out of his/her•failure to do tha wank provided herein;and <br /> 4. That in the event any claim of such liabil ty is made Wind theCoanty of San Ao,g or any ftertacut deist or employee them het shall <br /> defend,iodemuiiy and holcittnem and e1h of&=harmless for such claims and <br /> 5. That work shall be perfonued by the applicant and/or any representative ofthe applicant in the Comity Rigid-of-Way at the aboveindicated site <br /> with a valid Sas Joaquin County Fncroad menrt Permit;and <br /> 6. That Epenn ssion is granted as ragwsted,he agrees to do the work described in acombnoe with all temna,conditions and restriction of this and any <br /> attached sheet,mduded as general or slued III_nmg' <br /> Siffinalm'eofApplicaanl.TMe Date, <br /> FIELD INSPECTOR COrMfENTS <br /> »»»»»»»»»»»»»»»»»»»>BXISTINOCONDMON3«««««««««««««««««««« <br /> n <br /> L DRIVEWAY: Nage ❑ dict Ciravd ❑ Amerle,Base ❑ Pxvcd(t w) ❑ Pa-*Good) ❑ <br /> 2. SLOPING: Anay1romPavemant ❑ TowaodsPavmnent Flat [] <br /> 3. PIPES:. Nene Exisft-Type <br /> Othe+'Pipas mnei0borhood: Yes No ❑ Approaches A, Cross Drain ❑ Siwe <br /> Madinat to nawwallim Yes No ❑ <br /> L HEADWALF- Yea .❑ No <br /> S.ASPHALT CONCRM BUM- Yes ❑ No, <br /> i~.BARREMS ak"Right-at=Way <br /> 1. DTM Yes�No ❑ Ifyes:• V Style 2 Pi l t ❑ Other ❑ Width Dap1h <br /> PERMTTREQUIREIIENTS«««««««««««««««««««« <br /> 1.DREVE AY: Slrtt 001,10bfEttCL97, ❑ AGRtCUL.TUM ❑ INDUMMAL ❑ <br /> PAVED with "W,Dq)dh A.C.over A "MM Depth 3W AA <br /> Notes <br /> PaS a of Pipe� Ft.and Disin.da•of Pipe Inch <br /> To be comeded to any adjacent driveway pipe Yes t N, <br /> DRAINAGE INLET REQUIRED Yee ❑ No L^I� <br /> Tom (wkh p posed) Total N=eber of Stwxn Drabs Tackle <br /> Nates <br /> 3. HEADWALL Yes No <br /> A PAVED FRONrAgE: PAVED with "Mm.Depth AC.over "Mm Depth3/4"AB <br /> g Feetin tang&and Feat in width <br /> FEES <br /> Driveway b moachrue t Pannit base flee...........................585. <br /> Id Inspection <br /> Driveway w/or w/o pipe.. . .. _ _59500 ❑Paved traats$a_ .___. ....5100.00+8.46/ft <br /> Drivowayw/bos Qrlvat__ . _....._ _ ❑Crib,Gutter,Sidewalk..:.....:....__...$100.00+o.gg& <br /> Caunte AcOmpi ter,c: ccesslAppliaa8on for Penn hlDriynway and Paved Frontage Page.2.of 2 Revbbd=000 <br />