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THE APPLICANT HEREBY CERTIFUS: <br /> 1. That helshc has read an the provisions of this appfication,and that the dmwipticn included iuthis applic3fioa ace correct to the best of his/her <br /> knowhvdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability far Pascual injury or damage to property vdd&may arm out ofthe wohk described above, <br /> or which may arise out of hisAor faifure to do the work provided herein;and <br /> 4. That in the event any claim OfsuehWilily is made against the County of San Aoagiun or any department,official Of employee 11>ereoi;be shall <br /> defend,indemnity and hold thein and each of them harmless for suds Claim;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 Comely Eaabadsmed Peunit;and <br /> b. Tint if parmissian is granted as requested,he agrees to do the walk descdbed in acaocdaaca with an teams,conditions and restriction tion of Chia and any <br /> attached gawal III ptovhscons � � �r a� <br /> tl <br /> Sighsethue ofApplicu t-Titre <br /> FIELD INSPECTOR COPABIRNTS <br /> »»»»»»»»»»»»»»»»»>}»»M(ISTDW CONDITIONS«««««««««««««««««««« <br /> 1. DRftWAY: None ❑ Dirt ❑ Gravel AWvgft Base ❑ Paved(pcwr) ❑ Paved(Good) ❑ <br /> 2.SLOPING: Away from Pavamant @ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES:. Now 9 Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Sin <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No Q <br /> S. ASPIl'ALT CONCRETED Yes ❑ No R <br /> 6..BARRIERS aicw*Ri&-af•Way <br /> 1. DITCH Yes ❑ No N IfXes: V We ❑ 2 Point ❑ Otlsar ❑ Width Depth <br /> >;»»»>>>>> »»»»»»>»»»>PERMIT REQUIREMENTS«<<<<< ««««««««««««« <br /> 1.DRIVEWAY: SFR ®: COMMERCIAL ❑ At3RiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2— "Min,Depth Ac over g "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PVM& L-9*of Pipe Regapr Pt.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAt3E INLET REQUIRED Yea ❑ No 0 <br /> Total Lahgth: (with proposed) Total Number of Store Draia Islets <br /> Nates <br /> 3. EWADWALL Yes ® No . <br /> 4 PAVED FRONTAGE: PAVED with "Min.Depth AC.over "Min.Depth 3/4"A.B. <br /> Measuring Fed in keg&and Feet in width <br /> FEES <br /> Driveway Fnavachmant Permit base fee............................$85.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe.......... .. _. _..._.. ___ 595.00 ❑Paved froataga _.__._. _�..__ $100.00+0.46/& <br /> ❑ <br /> Driveway w/boxCulvert._......__.......... .. _..._.....__..S1S5.00 ❑curb,Gutter,SmawalL.......................$100.00+0.98/ft <br /> CourtetiComputer,c:VcasslAppliaatioa for PecmitaMriveway and Paved Frontage PaW.2 of 2 Revised 812000 <br /> ,4 <br />