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THE APPLICANT,MnSY CERT EMS: <br /> 1. That hecsbe has read ag the provisions ofth s awfication,andthet the in this amAcidware ooir t to the best ofd <br /> kwwlw�and <br /> That he/she is the owner of the respective property,or is qualified to reps the off;and <br /> I That he/she will assume full resl"WWity for all hoility for personal mjhry or dare to Wope ty v bicb may out of the WQiic <br /> or which may arise out of his/her failure to do the work provided but*—and <br /> 4. That in the event any claim of such liability is made against the County of Sar► ' ' or anydepufteak drww or ft*,Oyft$ervQ&ba <br /> defend,widen-lf,and hold them and each of them harmless&r such daxm6-and <br /> 5. That work shall be perfortned by the applicant ant anftr any rept five,oftbwapplicW is the COW*R*U-06-Way at the above hxB ated:ahe <br /> with a valid San Joaquin County Encroaduntnt Penn*and <br /> 6. That if pemaission is gated as he agrm to do the work desc;rahod in acowlaitce with all#oras,conditions and resttict*offs ted any <br /> attached included as gen or specialIII provisions, <br /> St ature of Applias t-Title <br /> F=D INSPZCTM C'C)ADffNTS <br /> 1. DRIVEWAY: N `. / Dirt ❑ Gravel Paved(poor) L-1 Paved(Good) <br /> 2 SLOPING: Away from Pavement [] Towards Paved EV Flat <br /> 3. PIPES: None (� Eiastirig-Type <br /> Other pipes in nei&Vmboo,&- Yes ❑ No r[+ � ❑ Crom Doin ❑: Sloe <br /> Attachment to neigbboes pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5.A;SPA'ALT C'QNCRIETE D Yes ❑ No <br /> 6. BARRIERS alongRi&,f-W-v <br /> 7. DITCH Yes Ko Yes; V Style ❑ 2 Peet (� fJtlax [❑ Wim, - '" <br /> >>>>>>>>>>>>>>>>>>»>>>>>>>>>>>>>>>>>>>>PERMIT REQS TS«««««««««««««««<.««««< <br /> L DRIVEWAY: SFR COMMERCIAL 0 AGRXI,T€:LME ❑ ❑ <br /> PAVED with "Min.Dept A.C.over "MinDep&3/4",AA <br /> Nates <br /> E7- <br /> 2. PIPES: L Vh of Pipe ReT*td: Ft ami DWWAW of Pipe Ineb <br /> To be connected to any adjacent driveway pipe Yes ❑ No { <br /> DRAINAGE INLET RF;QUIR.ED Yes ❑ No <br /> Total Length: (with pry) Totem Number of Sbum Drwk bleta <br /> Notes � .�..`.'. <br /> -- '. <br /> 3. HEADWALL Yes r] No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mitt.Depth 3/4"A.B. <br /> Measuring Feel in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee ......................S&5.0fl <br /> Field Inspection <br /> Driveway wr or w/o pipe.................................................$95.00 ❑Paved frontage.................................SIK00+0.46/ft <br /> Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewallc... SIQQ.QQ 0.98tf1 <br /> Counte6Computer,c:Access<Application for Perch\Driveway and Paved Frontage Page 2 of 2 Revised <br />