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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read alt the provisions of this applicatiog,and that the <br /> knowtwdge;and description included is this <br /> application ane correct to the best of his/her <br /> 2. That hMhe is the ovn f of the respective property,or is qualified to represent the owner and <br /> 3. That he/she will assume full responsibility for all liability for persond ir",y m.damage to prpedy which may amine out ofthe work described above, <br /> or which.may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of Sass kagima or,any official <br /> or defend,indemnify and hold them and each of them harmless for such claim and °yee off he shall <br /> 5. That work shall be performed by the aWlicauut and/or any rellresemtative of the applicant in the <br /> with a valid San Joaquin County Way at the above indicated site <br /> Flu �Y EnQoadsnseat Pew and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all tensa,conditions and restriction of this and any <br /> attached T gam(or <br /> vision <br /> Sit; ofApp&xmt-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> EMTM CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nie ` <br /> ❑ Dirt Gravel ❑ Aggregate B 'ase ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfivnr Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: No. Al Egg_Type <br /> Other AM in neigbmhoodL YesElNo Approadmes ❑ Craw Drain ❑ Size <br /> Attar t to Mei or's/ Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' / J <br /> S. ASPHALT CONCRETE;Dm: Yes ❑ No <br /> 6. BARRIERS along Tright-of-Wal, <br /> 7. DITCH Yes ❑ NoWJIfYes: V We ❑ 2 Point ❑ Other <br /> ❑ Width Depth <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>»>>»»»PERMIT REQUIREMENTS<z«««<<<<<<«««««««««« <br /> 1.DRIVEWAY: SFR /,►+I CO1�IIIdE$CIAE ❑ AGRICULTURE ❑ INDUSTRIAL, ❑ <br /> PAVEDwith" ]Win.Depth A.C.over _" " <br /> Mm Depth 3/4 A.B. <br /> Nates <br /> 2. PIPES: Leesgih of Pipe Required; Pt.and Diameter of pig <br /> Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ N. <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Nates Total (withproposed) Tonal Nruber orStorm Draht Inlets <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED wills " <br /> Dein.Depth AC.over "Mia Depth3/4"AB. <br /> Ming Few is length and Feet is width <br /> FEES <br /> F <br /> eway Fac roachmemt Permit base fix............................$85.00 nnriveway w/or w/o pipe.....___: ............................__$95.00 Paved +0.46/R <br /> _.... <br /> image -. ... .__ _ $100.00 <br /> ❑Drivewayw/boxC�slveit._....._............._. .$155.00 <br /> ......1— ❑Curb,Gutter,Sidewalk....................._$100.00+0.98/8 <br /> CountalCompi ter CAAooess\Application for PennilslDriveway and Paved Frontage <br /> Page.2 oft Revised 8/2000 <br /> i <br />