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THE APPLICANT HEREBY CERVI'+ ES:and dist iLe description included iatbis SPPBC26M am correct to the best of MAW 1 <br /> i. That he/she bas read ail the provisions of this gTH--ion, <br /> knowtwdge,and <br /> 2. That he/she is the owner of the respective properly,ar is qualified to represent die owl and <br /> 3. That hatshe will assume full repondhility for all tiabdity firpersoual i*r3'or damage to property which mxy arise out of the work described above, <br /> or which may arise out of his/her failure to do the wank provided herein;and <br /> 4. That in the event any claim of such liability is made against dheCounty of San Joagkm or any dam,ofEcat or employee dmeO&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 appha t and/or any rive of The applicant in the County Rigbt-Of--Way at the above indicated site <br /> c <br /> with a valid San Joaquin County Encroachment Permit;and <br /> b. That if Parmissieu is granted as requested,he agrees to do the wade described in accordance vMh all teams,aaoditi(m and restriction of this and any <br /> attached sheet included as gmeaxl or special III pcovisiona. <br /> C-Za c <br /> Date <br /> Slgndare of Apphcaflt-'Fual <br /> . <br /> FIELD INSPECTOR COMMENTS <br /> L DRftWAY: roue ❑ Dict ❑ ciravrol ❑ Aim Base ❑ Paved(t oer) ❑ Paved(Good) <br /> 2.SLOPING: Away Ecom Pavement ❑ Towards PaVeme9 ® Flat ❑ <br /> I PIPES:. Now X Existing-Type <br /> O&W pig in : Yes ❑ No IS Approaches ❑ Cross Drain ❑ Sin <br /> Attachment to neighbors pipe: Yes ❑ No <br /> 4 HEADWALL: Yes ❑ No <br /> S ASPHALT CONCRETE DIICE:': Yea ❑ Ne, <br /> 6..B4RRIERS ak"Rrgbt-o&Way <br /> I. DITCH Yes ❑ No IS Ifyes:- V We ❑ 2 Pia ❑ Other ❑ Width Depth <br /> PER.MITREQUp ZEIM NTS«<<<<< ««««««««««««<< <br /> 1.DRIVEWAY: SFR ® COMMERCIAL ❑ ACsR"MTME ❑ INDUSTRIAL ❑ <br /> PAVED with ?_"Min.Depth AC_avor _"kA.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPER: Lmmgth of Pip*Req*v& Ft and Biometer of Pipe inch <br /> To be connected to any adjacent Mvewmmy pipe Yes ❑ No <br /> DRAWAt3E INLET REQUIRED Yea ❑ No <br /> Total Length: (wtlh proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Wm Depth A.C.over "Wmn.Depth 3/4"A.B. <br /> Measuring Feet is length and Fedin width <br /> FEES <br /> Driveway Enanachment Permit base fee............................$85.00 <br /> Field Inspection <br /> Drivewayw/or w/o $95.00 E]Paved finutaga _._. .._ 5100.00+0.46/ft <br /> ❑Driveway w/boxCulverL._......_.._........_...._..............$155.00 ❑Curb,Chatter,Sidewalk......................$100.00+0.98/ft <br /> Revised$/2000 <br /> Counter�Computer,c:1A�ss\Application fir PeamitslDriyeway and Paved Froze Page.2 of 2 <br /> d \` <br />