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1. That helshe has rel all the provisions of this appficntiorr,and that the description inclu&d ie thus application ane correct to the bast of his/hea <br /> Imowh*e;and <br /> 2. That he/she isthe owner of tha respective propetiy,,cr is qualifiedto represent thoowner and <br /> 3. That he/she will assume fall vesponsibilify for all liability for Personal iqJW'y or damage to property which may arise out ofthe work described above, <br /> or wh&way arise out of Ws&w£ailuro to do the work provided her in;and <br /> 4. That in the event any claim of such liability is made against%&Castnty of San Aagim or any dVart meat,official or employee there4 be shall <br /> defend,indemnify and holdthan and each of than harmless for such claims and <br /> 5. That work shall be peed by the applicamtt and/or any representative ofd,applicant in the Courtly Right-of-W y at the above indicated site <br /> with a valid San Joaquin County Eoaoacha eot Peraft and <br /> 6. That if pam ission is granted as req vested,he agrees to do the work described in acoardance with all.terms,conditions and restriction of this and any, <br /> attached inrludedasgeneplat'specW111pr+ovisims. <br /> ' 3igae�sofApplir�!-Titter <br /> FIELD INSPECTOR C EM30M <br /> »»»»»»»»»»»»»»»»»»»E)M3T gGC(3NDM0M««r«««««««««««««««««< <br /> t <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel Aggregate lyse Pavokpoof) ❑ Paved(Good) ❑ <br /> 2. SLOPING Amyfram Paoemaot ❑ Towards P—a-mit -❑ FLt <br /> 3: PIPES:. Now Existing-Type <br /> Otherpipesina ochood Yes ❑ No Approaches 0 Cross Drain ❑ Sine <br /> Attadimatt to pipe: Yes ❑ No <br /> 4. HHEADWALI_ Yea ❑ No' <br /> ASPUALT CONCRETE DIKE: Yes ❑ No <br /> 6..BARRIERS agog Wiry <br /> 1. DITCH Yes ❑ No g iMe. V Style ❑ 2 Pim ❑ 0&. ❑ Width DgAh <br /> »»»»»»»»»»»»>> >PERMITREQUIRElENTS<z««««««««««««««««««« <br /> 1.D]lffn1 KAY: SFR COMWERCIAL ❑ AC#RtCULTt7M p INDUMVIAL ❑ <br /> PAVED with 2 ."Mia Depth AC over 4 "V .Depth 3/4"A.13. <br /> Norm <br /> 2. PEMSe Leug*of Pipe Re**sd:• PL and Diud.06W 4f Pipe inch <br /> To be concmected to any a4aoernt driveway pipe Yes ❑.No <br /> DRA WAOE INLET REQUIRED Yea 0 No <br /> Tow Length: (with p posed) Total Nmuber of Stogy Drama Iii <br /> Nates <br /> 3. EWADWALL Yes Q No . <br /> 4. PAVED FRONTAgE: PAVED with "Mm.Depth Ar_over "Ma Depth 3/4"A. <br /> Measuring Feet in tenth and Feet in width <br /> FEES <br /> Driveway pnaoochmat Permit base fee..........:.................$85.00 <br /> Field Inspection <br /> ❑Drivewayw/or w/opipa.._..._ ._�._ _._.._S95.00 ❑Paved fimaftga.___.__:_.____.5100.00+0.46/8 <br /> ❑Drivewayw/boxCulyart._ _ _ .. _.SiSS.00 Elten <br /> Cue%(k ,Sidewatic..:.._.. ...... . $100.tm+0.98/8 <br /> Ceuntakcamputea•,cAAcceealApplication for PamWMl yeway and Paved Frontage Page.2.of 2 RAvlaed V2000 <br /> t , <br />