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THE APPLICANT HEREBY CERT HIES: <br /> 1. That he/ahe hes read all the provisions of this bion,and that 1>>e deseriphott inc4aded iatlais application am correct to do best of his/her <br /> knowhvd5e;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner and <br /> 3. That he/she wiil assume full respaasihilily for all liability fir personal injury or damage to property whichmay arise out ofthe work dmcdbod above, <br /> or which may arise out of his&er failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against theCoady ofsm,Boagikm or any deportment,official or employee thereot;he shall <br /> defend,kdwanify and hold*=and each of than harmless for such chi mad <br /> 5. That work shall be performed by the applicant and/or any representative of taecant in the <br /> � County Right-of-Way at the above indicated site <br /> with a valid San J <br /> oaquin Courtly F.ncroadnnuit Parte and <br /> b. That if pemaission is IpMed as raqmmted,Jac agrees to do the walk described in acoordaace with all <br /> tams,conditions and restriction cfthis and any <br /> *oet,' M provisions. <br /> � . e- 9 <br /> sigoahaeofAppt-Tine Daft <br /> FIELD INSPECTOR CObfl1MPf S <br /> »»»»»»»»»»»»»»»»»»»»EXI.STiTiCi CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nage Dart ❑ caravel ❑ Aggregate Base ❑ Paved(Iwor) p Paved(Good) ❑ <br /> Z SLOPING: AwayfronaPavamant p T..bPaVemaot ] Flat ❑ <br /> 3. PIPES- Now Existing-Type <br /> Other pipes in naiglaborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Stu <br /> Attachment to nagfdnor'a Yea F-1No <br /> 4.HEADWALL: Yes ❑ No' <br /> S ASPHALT CONCRETE DIICE:' Yea ❑ No <br /> 6..BARRIERS aloagliW-af Way <br /> 7. DITCH Yes ❑ No It Ifyes: V Style ❑ 2 Point ❑ Other ❑ Wad& Depth <br /> PERM1TREQUIREMENTS««««««<< <<<<««««z«««< <br /> 1.DRIVEWAY: SPR CObIIWEI CIAL ❑ AGRiCULTEIRE ❑ IIVDUSTRIAL F1 <br /> PAVED with "Min Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Length of Pipe Required: Ft.and Diamder of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No — <br /> DRAINAGE INLET REQUIRED Yes ❑ No K <br /> TOW (MrA Propsed) Total Number of Storm Drak Iale4s <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over ^bfm.Depth 3/4"A.B. <br /> Mpg Feet in tent and Fed in width <br /> FEES <br /> Driveway Fhanadumaffi Permit base fee................_..........$95.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.......... <br /> ❑Paved fivatage...—..._._.-._._....__....5100.00+0.46fR <br /> ❑Driveway w/box Glrlvat._...... .......... .._ .._..._.._..5155.00 <br /> o:1Access\Application for PerruitWkiyeway and Paved Frontage Page.2 of 2 <br /> Revised 82000 <br />