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THE APPLICANT HEREBY CERTg7ES: - <br /> 1. That he/she has read all the provisions of this Vocation,and that the description included iatbis application we correct to the best of hiWhec <br /> knowhvdge;and <br /> 2. That he/she is the owner of the remove property,or is qualified to represent the Owner;and <br /> 3. That he/she will assume fall responsdility for ail liability forpaaami injury or damage to property which may arise out ofthe work described above, <br /> or which may arise out of hiAer failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against ihoCoudy of San Aoagian or any ltd,official or employee thereat;he shall <br /> defend,mdemhify and holdthem and each of them hasmksa for such claim;and <br /> 5. That work shall be performed by the applicant and/(r any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Fncroacbntmt Permit;and <br /> 6. That if permission is grgpd as requested,he agrees to do the wort in acoerdance with all tams,conditions and restriction of this and any/ <br /> attached sheet,WOWWas what or M <br /> Signe ofApplicar�T' <br /> FIELD INSPECTOR COMMENTS <br /> gXESTM40 COTTONS«««««««««««««««««««« <br /> L DRA IEWAY: None ❑ Din Gravel ❑ Amq;meBan ❑ Parc-or) ❑ Paved(Good) ❑ <br /> 2.SLOPING: Aaa from Pavement ` Towards Pavement ❑ Flat ❑ <br /> 3. PIPES- Nana Existiog-Type <br /> OthapipesinaAghthorhood: Yes El No Approaches F-1GYossDrain ElSim <br /> Attachmeat to tis pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S ASPIAALT CONCRETED Yes ❑ No <br /> 6..BARRIERS along Right-of--Way <br /> 1. DITCH Yes ❑ No IfYes: V Style ❑ 2 P6int ❑ other ❑ Width Dept <br /> »»»»»»»»> > >>>»»>p REQ TB«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMad UCIAL ❑ AGRICMT1 RE ❑ INDUSTRLAL ❑ <br /> PAVED with 2 "hQio.Depth AC,over "Mm.Dopar 3/4"A.B. <br /> Notes <br /> 2. PIPL& LMgth of Pipe R-Fir"t Ft.and Diameter of Pipe inch <br /> To be connected to nay ad*" pripo Yes ❑ No�— <br /> DRAINAOE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Dr0dha Islets <br /> Nates <br /> 3. EMkDWALL Yes ® No <br /> 4 PAVED FRONTAGE: PAVED with "Mie.Depth A.C.over "hfmL Depth3/4"AB. <br /> Measuring Feat in length and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> F1d Inspection <br /> Driveway w/or w/o pipe........_..........._.------- 595.90 ❑Paved +0.46/& <br /> Driveway w/boxculvert.._....._................ _..$155.00 ❑curb,Gutter,SidewalL.....................$100:00+0.98/ft <br /> CountakComputer,c:V=easlApplioatiou for PermitsWriveway and Paved Frontage Page.2 of 2 Revised8/1000 <br /> f <br /> t \ <br /> A <br />