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THE APPLICANT HEREBY E�and that the desmipticn k clodad iathis applxatidm are to the best of his/her <br /> I. That he/she hes read all the provisions - <br /> Imowlwdge,and <br /> 2. Tbat balshe is the owner of the eve PrnPedY,or Fis quahfiedto regresat tbeownm and <br /> 3. Tbat heldie will assume full respamsibu7ity <br /> far all#iAirdy fnrpersonai injury or damage to props y which may out ofthn work descn'bod above, <br /> or wbich may arise out of his/her failare to do tie work provided here and official shall <br /> 4. That in the event any claim df such liabt'h'ty a made agaimdt%v County of San 7baci m of tarry <br /> defend,indemnify and hold*=and each a£them bmnnlesa for such clairq and �way at the abova indicated site <br /> 5. That work shall be performed by the applicant and/or any reprea�8*-of die applicant in the County Right <br /> with a valid Sao JoadPrin COSY EAcrOachtneat Pest and <br /> 6. That if pwmisaraa is Smated as requested,he agrees to do the wo&described in acoardsane w tdt all tears,canditioos and t estridion of this and any <br /> attached sheet,included as gexidxai°r special M provisions. p� <br /> SFigaoW of.Applic..t-Tine Data <br /> FIELD INSPECTOR CUIIDVIENTS <br /> 7»>EXISTMOCONDITIONB««««««««««««G««GGG«««<< <br /> 1. DRIVEWAY: None Diit ❑ Gravel ❑ AffagateBan F] Favea(Poor) ❑ Pavod(Good) ❑ <br /> 2. ROPING: Awayfin a Pavement ❑ Towanda Pavmrmt ❑ F <br /> 3. PIPES: No, Esq-Type <br /> Other pipesinneiobo&ood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attachment to s per; Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' ' . <br /> s. ASrffALT COPNCRETE DffO: Yea ❑ No <br /> 6..RARRTERS ak $Ei&-a-way <br /> 1. DITCH Yes ❑ No Ifyes:• V Style E] 2 Pbiut ❑ Other ❑ WidthDepth <br /> >>>>>>>>>>>> >»»»»»»»»»»PERMIT REQUIREMENTS«<<<<< ««««««««««««« <br /> 1.DRIWWAY. SFR COMMERCIAL ❑ AGRfCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Mi Depth A.C.over. "Ii.Depth 3/4-A.B. <br /> Notes <br /> of Pipa lt FL and Dia dOw of Pipe Inch <br /> 2. PIPE& <br /> To be connected to any adjacent dtivewaY Pipe Yea ❑ No UrSL_ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Tow Leigth: (with proposed) Tobd Nm aber of Storffi Dann Iskts <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Ids.Depth A.C.over "Min.Depth 3/4-A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Eaaneddn ent Permit base fee................_........ <br /> � <br /> Field Impaction <br /> Drivewa w/or w/o S100.00+0.46/ft <br /> Y Pipa...........:_..._._.._.....__.......... 355. ❑Pavedfi�catage.—•..._._..:....._.__.... <br /> [[Ell DrivowaywfboxCuhmt._._.. ....................... .$155.00 ❑Curb,Gnaw.Sidewa&..............._.....$100.00+0.98/ft <br /> Revised 8/2000 <br /> CautterlC`.omputer,cAAccessV+plicsdion for Pemrits\Driyeway and Paved Frontage Page.2 of 2 <br /> i <br />