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THE APPLICANT HEREBY CE.RTHUS: <br /> 1. That he/she has read all the provisions of this apOicg�and that the dssmiphou inebaded inthis application are correct to the best of his/her <br /> knowhvdge;and <br /> 2. That he/she is the owner of the rive property,or is qualified to represent the owner and " <br /> 3. That halshe will assume full resImabitity for all liability for personal injury or damage to properly which may arise out ofthe wozic described above, <br /> or which may arise out ofhis&w failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made agaimt theCowly of San 7oaqita or any depart,official or employee thare4 he shall <br /> defend,indennify and hold them and each of them harmless for such clawK 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 Conrsty Permit;and <br /> 6. That if permissi as to do the wait described in accordance with all terms,conditions and restriction ofthis and any <br /> attached geaaal visions. <br /> Signature ofAppliceflR'TMe Dat <br /> FIELD INSPECTOR COAEMZNTS <br /> »»»»»»»»»»»»»»»»>}»»gXISTIQ CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nacre Pit ❑ Gravel ❑ Aggregate Base ❑ Paved(p—) ❑ Paved(Good) ❑ <br /> 2. SLOPING: AvmyfvmPavamaut ❑ TowardsPavamed ❑ Flat <br /> 3. PIPES Now IW Exiatmg-Type <br /> Odwpipes inneigbbmhood: Yes No ❑ Apprusdwa ( Ctoas Drain Size <br /> Attachment tonoighbot9Yes ❑ No <br /> a we- <br /> 4.HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIICE:' Yes ❑ No <br /> 6..BARRIERS along Rigbi-oMay <br /> 1. DITCH Yes No ❑ IfYes: V We 2 Pint ❑ Other' ❑ Width Depth <br /> »»>>>>> »»»»»»»»»»PERMIT REQUREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR /fCOMMERCIAL ElAGMCULTURE F1 INDUSTRIAL ❑ <br /> PAVED with 0 "Wm Depth A.C.ova It <br /> "Mm Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Lasgth of Pike R Fkod: PL and Damtater of Pipe inch <br /> To be connected to any adjaoent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No / <br /> Total LM90L (with proposed) Total Number of Sturm Dram Inlets <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "hf n.Depth 3/4"A.B. <br /> Measuring Fed in leaglh and Feet in width <br /> FEES <br /> Driveway Faabaclment Permit base free............................$85.00 <br /> Fi w InapaNion <br /> Aswaway w/or w/o pipe.......... .._._.._._. ___ $95.00 ❑Paved fiv tags..._..._................._....$100.00+0.46/R <br /> ❑Driveway w/boxCulvert.......................__... .. .._ $155.00 ❑Curts,Guaw,SidowatL.....................$100.00+0.98/8 <br /> CountakComputa,c:lAccess\Applioation for PermilsiDriyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br /> i <br />