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I. That he/ft has read all the provisiom of fids appplication,and that the desdxilAion inck:dad iathia application are correct to the best of his/her <br /> knowhwlm and <br /> 2. That tkatshe is the owtner of the respective propetty,or is qualified to rqwesmt the owner;and <br /> 3. That he/she will assume full miry Ewa y fat'Pasonsi mlm9 a'dumSe to ley wik hmay arise out ofthe work described above, <br /> or wbichmay arise out of his&er Sihue to do the workprovidedherak and <br /> 4. That in the event any claim of sei&liabsAily is made agaies!ffieCo,nty of San Joaqi6normydepatnaent,oTwid or employee there4 he shall <br /> defmd,indemnify and holdtim and each afore,barmiess for such chwx and <br /> S. That work shall be perfactned by the applicant and/or any repVe of the applicant in the Courtly Right-of-Vinay at the above indicated site <br /> with a valid San Joagain County Frxroadhnhent PM*and <br /> 6. That if pamissim is granted as requested,he agreas to do the wo&described in scaerdance with all.tams,oonditieas and restriction of this and auy <br /> attached sheet,hufuded as a7/7! <br /> Signates•aof Tule, Date <br /> FIEIM INSPECTOR COMMIRM <br /> »»»»»»»»»»»»»»»»»}»»EXISTMQCONDITIONg«««««««««««««««««««« <br /> L DRAILWAY: Now ❑ Dur Gmvvl ❑ AM"ate Base, Paved(Good) ❑ <br /> 2. SLOPING: Avmyfrohn Pavammt Towards Pavamaot ❑ Flat ❑ <br /> 3.' PIPE&. Now Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approadws E Crow Drain ❑ Sin <br /> AtWAmat to ndgbborls pipe: Yes ❑ No <br /> 4.HEADWALE. Ym ❑ No <br /> S. <br /> ASPHALT OONCRMM Dffi5e , Yes ❑ No ❑ <br /> .BARRIERS 81onF RWg 0&way <br /> 1. DTTCS Yea ❑ No IfYes:• V Style ❑ 2 Pont ❑ Ohw ❑ Widlh Depth <br /> 1.DRIV WAY: SFR COMMERCIAL ❑ AC#RtCULTEIR$ ❑ INDUSTRIAL ❑ <br /> PAVED vri& Mm.Depth A.C.over "Mm.Depth 3/4"A.B. <br /> Notre <br /> 2. YIPS& Larglh of Pipe,R-Pko&' FL sod Moulder of Pipe Inch <br /> To be ooanected to mya4weat driveway pipe Yea .No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Laogth: (with proposed) Total Number of Storm Drab Isfets. <br /> Notes <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAgE: PAVED with "Min.Depth AC.over "Mia.Dep&3/4"A.B. <br /> Measuring Feet in laugh and Feet in width <br /> FEES <br /> Driveway Faavachmemt Pernik baso fee_--,................ <br /> lee..._.:.................. 583.00 <br /> Field Impec doe <br /> �&Drivewayw/or w/o pipe.. ..... i.00 ❑Paved fnaatage__-- - -- __ 510040+0.46/8 <br /> ❑ ❑cud),Gutter,Sidevvallc..: _....S140.00+0.9878 <br /> CounterkCompi ter,cAAmessVipplication for PwmWTkiyeway and Pawed Frontage Page.2 of 2 Revised 8!`1000 <br />