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TILE APPLICANT HEREBY f�and that the description jwk ded ietbis apglic&ion are correct to the best of his/her <br /> 1. That he Lille bas read all the provisions <br /> knoWlvaige;and <br /> or is qualified to represent the owner,and <br /> 2. Tbat helshe is the owner of the respectivepaepaty, or dam to Pte'which may arise out of the work described above, <br /> 3. That helshe will assume fn11 r uW far all liability for personal injary <br /> or which may arise out ofh wlff failure to do the work provided herein;and offC3al or oyee thereo�bemall <br /> 4. That in the event any claim of W&liability is made a %a County of San xmm*m or any dep-tuent, <br /> defend,Inde mjfy and hold*=and each of them harmless for suds claim;and �Wa at the above indicated site <br /> 5. That work shall be performed by the applicant and/of any mpresetative of the applicant in the County�ght y <br /> with a valid San Joaquin County F it Permit;and <br /> weak described in acoordsnce with all terms,oonditioos and restriction of this and any <br /> 6. That if permim, as he agrees to do the <br /> a2taebed or specrai TQ provssaons <br /> Date <br /> Sigmtme,ofApplicxmt Title <br /> FIELD INSPECTOR COMMENTS <br /> >>>>>>>>>>>>>>>>>>>>,>>>>>>>>>>>>>>>,>>>>>EXISTx <br /> MO CONDITIONS«««««<<<<< ««««««««« <br /> A Bao EJPavedamr) ❑ PavekGood) ❑ <br /> 1. DRIVEWAY: None ❑ Dirt El Gravel F El 2. SLOPING: Awayfrom Pavaanent Towards El El <br /> 3. PIPES:. Now ElExiling-Type QlauA AD (Wk-nq <br /> Other pipes in <br /> Yes No Approaches ❑ Cross Drain ❑ Size <br /> Alta topVc: Yes ElNo <br /> 4. HEADWALL: Yes ElNo iff <br /> S. Agmmu coNcRETL DIKE: Yes ElNo <br /> 6. BARRIERS along Ri&-cf Way <br /> yes ❑ No IfYea: V Style [-] 2 Point ❑ Otho' ❑ Width Dem <br /> 7. DITCH , <br /> »»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS <br /> ««««««««««««««««««« <br /> 1.DRIVEWAY: SFR <br /> COMMERCIAL ❑ AORtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with ?/ "Ikfm Depth A C.over "Mm Depth 3/4"AB. <br /> Notes <br /> 2. PIPE& Lag$of Pipe Required: Ft.and Diauidar of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes El No IQ�� <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> TOW Length. (with proposed) Total Nu®bw of Storax Drahk Inlets <br /> Notes <br /> 3. HEADWALL Yea ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> Wm Depth A.C.over "Mos Depth 3/4"A B. <br /> Measuring Feet in kng&and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection <br /> D9veway W/of W/o pipe.........-:..---------....__------_.._. <br /> $95.00 ❑PavalS100.00+0.46/ft <br /> . R ❑Curb,(hate'.Sidewalk.......................$100.00+0.98/R <br /> ElDriveway W/box Calve ........_............._.......................$155.00 <br /> Revised 8/2000 <br /> CountealComputa,c-Vxcess\Applioaion for pamiWgXiveway and Paved Frontage Page.2 of 2 <br />