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and that the description inckeded iatWs appiicatioa arecower to the bast of his/her <br /> 1. That he/she has read all the pra6siOw of This mom% <br /> kwwlwdgg and <br /> ve oris edto ugrasmt The ov ma;aad <br /> 2. That he/sho is the owner cf the rasped- proPa►tY, fi whkh ny aria out of the work dambed above, <br /> 3. That helshe WM assume fall rWo0jhft all flAifijy forpwmal wM or damage to F%WtY <br /> or wbichmay arim out ofbislher(ailuro to do the workprovidadl:eroia;and official or employee,9WXV4116 ahail <br /> 4. That in the oveat any claim of such lidaility is made agaigd*eCounty of San]bads or any depmtnent. <br /> defmd,indemnify and holdtheah and each of them hamzleas for such claims and Wap at the above indicated site <br /> S. That work ahall be performed by The appliexs8 andtar any rWmdx&c of ft scant in the County gbt <br /> with a valid Sao Joaquin County Fent Pewit;and <br /> with all terms,oondotiens and restriction ofihia and any, <br /> 6. That if peanissian is granted as requested,he agrees to do the work desm in k <br /> attached amt, as, or spacial III provisions. <br /> Date <br /> ofTille <br /> FIELD INSPECTOR COIF <br /> L DRIVEWAY: None Di F, Gmvod E] AW od.Base ❑ Paved(poor) ❑ Pa,*Good) El <br /> 2. SLOPING- Away <br /> ftm PAva rent ❑ Towards Pavmmeat ❑ Flat <br /> 3. PIPES:. Now 'Type <br /> Other pipes is <br /> Yes ❑ No Approad. 0 Cross Drain EJ size <br /> Attadton 'a Yea ❑ No <br /> 4. gEADWALl.: Yes ❑ No' /. <br /> S ASrEFALT CONCRM DIItI►: Yes ❑ Na <br /> 6..BARREMS a10148 RW-0&W2y <br /> '!. DTfCS Yes ❑. No IfYes:• V Stale ❑ 2 Point ❑ Other ❑ <br /> «««««««««««««««««««« <br /> j COMMERCIAL ❑ AGRICULTURE ❑ INDU917RIAL ❑ <br /> 1.DEMEWAY: SFR O <br /> PAVED with Z= -"Its Dep&A.C.over. "mm.Depth3/4"AB. <br /> Nates <br /> 2. PIPS& Lmb Pt.and Disv0cr of Piga <br /> To be connected to soy adisoent driveway pipe Yes ❑..�((No KL <br /> DRAM INE ET REQUIRED Yes O No ISLE <br /> Tohtl L:ngth: (wigs proposed) Total Number of Storm Drams Iib <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mi Depth A.C.over "Min Depth 3/4"AB. <br /> Measuring Feet in tm%g and Feet in width <br /> FEES <br /> Driveway Fnaoadxmeut Permit baso fee................_..... ...585.00 <br /> r�i> on <br /> w/arw/o _S95_ ❑Pavedfircata$a--.--�-----_....$100.00+0.46/ft <br /> Y pipe.......... _ _.___ _ 0.98 <br /> $100.00+ /& <br /> ❑Driveway w/box Colvat._.................._........... $155.00. ❑Cmb,Gutter,Sidavvalk..:_... ...._.. <br /> Revised V2000. <br /> Counter\Compi ter,cAAooess\Applioation for PffKuW Ykiyewsy and Paved Frontage Psge.2 cf 2 <br />