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THE APPLICANT HEREBY CERTIFIES:and that the des,ption secluded ahis application are correct to the best of his/her <br /> 1. That be/she has read all the provisions of this WficatiOr,, <br /> Imowivrdge;and <br /> 2. Than he/she is the owner of the rive property.or is qualified to represent the owner;and <br /> 3. That he/she will assume full reaponsibilrty fix <br /> all may farpersonal jujuryor damage to Propel,whrchmay arise out ofthe work described above, <br /> or which way arise out of War=failure to do the work provided herein;and <br /> flee of San To or any deparhneuk oftiat or employee theme he shall <br /> 4. That in the encu(any claim of such liability is made agauost Cly � <br /> dared,indemnify and holdthem and each of deem harmless for sacs claux and Ri �Way at the above indicated site <br /> 5. That work shall be perforated by the applicant and/or any representative of the applicant in the Courcy t� <br /> with a valid San Joaquin County E.moadammt Pemf;and <br /> emission is granted as requested,he agrees to do the work described is accordance with all tests,000"ons and.restriction this and any <br /> b. That if permission <br /> attached sheet,included as general ar epe dd III provisions. <br /> Date <br /> Signshare ofApplicami-Title <br /> FIELD INSPECTOR COMMENTS <br /> ONS««z«««««««««««««««««< <br /> »»»»»»»»»»»»»»»»»>}»» <br /> EXISTINGCONDITIONS <br /> Caravel ❑ AWvgate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> L DRftWAY: None Did ❑ Flat <br /> 2. SLOPING: Mmyfrom Pavement ❑ Towards Pavmsatt ❑ <br /> I PIPES: Now Emoting-Type <br /> Other pipesinneigbbo Yes ❑ No Approaches E] Cross Drain El Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S.ASPHALT CONCRETE DIICL:' Yes ❑ No <br /> C.BARRIERS along Rio-cf Way <br /> Yes ❑ No ® If Yes: V Style E] 2 Point ❑ Olhec ❑ Depth <br /> 7. DITCH , <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS <br /> «««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ( COMME$CIAL ❑ AORJCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2— "W=Depth A.C.over "Ma Depth 3/4"A B <br /> Notes <br /> 2 PIPES: Length of Pipe so <br /> FL d Diamider of Pipe -- I <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Toed Largux (with proposed) Total NumLer of Sterni Drmfa lapels <br /> Notes <br /> 3. HEADWALL Yea ® No . <br /> "Mau.Depth A.C.over "Ma Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with <br /> trtea g Feet in length and Feet in width <br /> FEES <br /> Driveway Fnanacbment Permit base fee............................$85.00 <br /> FieidInspection $100.00+0.46/S <br /> Driveway w/or w/o pipe......... :.. . .._. . .. ...__ ._ $95.00 ❑Paved frmtaga _._. _ ____ <br /> ❑Drivawayw/boxC�s(vert._._...__.........._. ..........$1SS.00 ❑ <br /> Cb,( ar',Sidewalk.......................$100.00+0.98h <br /> CountelComputer,c:�Aa easlAppliaation for Permitsllkivewaynnd Paved Frontage Psge.2 of 2 <br /> Revised 8/2000 <br />