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I. That W&c Inas read alt the prdvisiow of this app foxy and Sat the desork ion inctoded mid&appfication are correct to the best of his/her <br /> lmowlwdgr,and <br /> 2. That he/she is the owner of the regmc ive propedy,or is qualified to represent thoovnw,and <br /> 3. That hedshe will assame fall roily for aft HAWdy for personal injary or damage to property vd whmay arise out cf&o work described above, <br /> or which may arise out ofhiAw failure to do See workprovided ham;and <br /> 4. That in the event any claim of mach tiabifity is made against OwCosndy of San loac or my depastwvt,of&id or empk*w thereof,he shall <br /> defend,indemnify and holdtbem and each afthem harmless for sods claim;and <br /> S. That wale shall be performed by the Whc 3*and/or airy re menta Ve Of the appficant in the Courtly Right-of-Way at the above indicated site <br /> with a valid San 7oagaia Coady Eamachmat Penni and <br /> b. That if pemcimsim is pard requested,he agrees to do She wads described in aooa danoe with all texas,oanditions and restriction of this and any <br /> attectced sheet,iarhtdo as enerai or c <br /> •— 0 <br /> Date <br /> FIELD IT WECTOR CO114W,M <br /> L DRftWAY: Now ❑ Vut Grx-d ❑ Agp"deBase ❑ Paved(I+oor) ❑ Ps9ed(Good) ❑ <br /> 2. Sr"ING.' Away fwmPavement ❑ Towards Pavement ❑ Flat <br /> 3: PBV,&.. Now Exisfg-Type <br /> Othapipes ianeighbedhood Yes ❑ No Approaches E Croom Drain ❑ aim <br /> Atlactma t to nagWwea pipe: Yea ❑ No <br /> & HEADWALL: Yea ❑ NO <br /> S. ASPHALT CONCRETE D=- Yes ❑ Na �I <br /> r~.BARREM A)114 <br /> 1. DrMH Yea ❑ No IfYes:. VStyle ❑ 2Point ❑ 06w ❑ Width Dq& <br /> »»»»»»»»»»»»»»»»»» <br /> PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRfVVZ.WAY: SFR ❑. COMMERCIAL ❑ A[tCLJ V= � INDUSTRIAL ❑ <br /> PAVED with t) "MhL Depth A.C.aver. Mia Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Lma*of Pipe Regaire&' Ft.axed Diameter of Pipe Inch <br /> To be oon6oted to anyadjaaat driveway O" Yea ❑.No <br /> DRAINAGE Dff"&SQUIRED Yea ❑ No N <br /> Tow Langur: (w&proposed) Total Nwm6er of Sta w Drata Iisleb <br /> Notes <br /> 3. EWADWALL Yes Q No <br /> 4. PAVED FRONTAIC{E: PAVED with "Min.Depth AC.over "Mm.Depth 3/4"AB <br /> Measuring Fact in tength and Feet in with <br /> FSS <br /> Driveway Faaoad ment Pamh base fee..............._.......� <br /> Field Inspection <br /> [&Driveway w/or w/o pipe......___.. _ _59 00 ❑Paved +0.4&t <br /> ❑Ddvewayw/boxcuivaR._................................_......_.$155.00 ❑Cxxh,Gutter,SwcwalL..:...................$100.00+0.98/$ <br /> CwnteAComputer,c.VWessA*i=fion far PeamWkDriyvmy and Paved Frontage Pagel of 2 Revised 8/2000. <br />