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THE APPLICANT HEREBY CERTIFUS: <br /> 1. That he/she has read all the provisions of this application,and that the description inckxW in.this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective properly,or is qualified to represent the owner,and <br /> 3. That he/she will assume firh responsibility for all liability for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of his/her failure to do the work provided havin;and <br /> 4. That in the event any claim of such liability is made against the County of San Joagiun or any dope ,official or employee thereof;he shall <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of The applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Eacroaohmeut Qenuit;and' <br /> b. That if pemrission is gra as requested,he agrees to i" work described in accordance with all tenns,conditions and restriction ofthis and any <br /> attached shoe or special vial <br /> Si o -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»>>EMSTINO CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt Gravel ❑ Base ❑ Paved(poo) ❑ Paved(Good) ❑ <br /> 2. SLOPING: A from pavement ❑ Towards Pavm..t ❑ Fly y� <br /> 3. PIPES: None 19 Exrsting_Type <br /> Other pipes in mood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attacunent to neighbor': Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DACE: Yes ❑ No <br /> 6. BARRIERS along Right-of Way <br /> 7. DITCH Yes ❑ No If Yes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PREQUIREMENTS«««««««««««««««««««« <br /> I. DRIVEWAY: SFR <br /> El7 AGRICULTME ❑ INDUSTRIAL ❑ <br /> PAVED with 2 -"Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Rmphvd: Pt.and Diameter of Pips --- Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Draft Inb to <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Mia Depth 3/4"AB. <br /> Measuring Feet in kngth and Feet in width <br /> FEES <br /> Driveway Eamachment Permit base fee............................$x5.00 <br /> Field OsViection <br /> Driveway w/or w/o pipe......................................_.......$95.00 ❑Paved SI00.00+0.46/ft <br /> ❑Driveway w/boxCSuly'L................................................$155.00 <br /> ❑Curb,Gutter,Sidawa]k.......................$14D.00+0.98/ft <br /> Counter\Computer,c:\Access\Applicetion for Permitsoriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />