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THE APPHCANT BEREBY CERT HS: <br /> 1. That he/she has read all the provisions of this application,and that the description incbuded'in this application ate correct to the best of his/her <br /> knowlwdge,and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. <br /> That he/she will assume fall responsibility for all liability fior pen"MI.m1ury or damage to property whichmay arisc out of-the work described above, <br /> or which may arise out of his/her failure to do the work provided herein,and <br /> 4. That in the event any claim of such liability is made against theCoouty of San 7oagera or any department,oll wW or employee thereoC he shall <br /> defend,indem<*and holdthem and each of them harmless for such claim;and <br /> S. That work shall be performed by the applicant and/or any representative ofthe applicant in the County Rigbt-of-Way at the above indicated site <br /> with a valid San Joaquin County Enavachmant Peninit;and <br /> 6. That if permission is granted as requested,he agrees to do the wank described in accordance with all tensa,conditions and restriction of this and any <br /> attached sheet,included as genal or special III provisions. <br /> Signature ofApplicaat-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTMO CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Out ❑ Gravel ❑ Aggregate Base ❑ PaVd(P—) ❑ Paved(Good) ❑ <br /> 2. SLOPING: AwayfromPavemed ❑ Towards Pavement ❑ Flat <br /> 3. PIPES:, Nome Existing-Type 19 / La gz GAT F,D M A L <br /> Other pipes in nd&bodmd: Yes (K No ❑ Approaches ❑ Cross Drain ❑ Stu <br /> Attadiumeat to neighbor's pipe: Yes ❑ No ❑ <br /> 4.HEADWALL: Yes ❑ No' <br /> S ASPSALT CONCRETED Yes ❑ No, <br /> 6..BARRIERS ak"Right-of.Way <br /> 1. DITCH Yea [3 No ❑ IfYea: V We gr 2 Point p Oher ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»PERMITREQUHMIENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ® COMWIMCIAL ❑ AGRtCULTtJRE ❑ INDUSTRIAL ❑ <br /> PAVED with Z "hdm.Depth A.C.over �_"W.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Lmgth of Pipe Regaaod: FL and Duni r of Pipe Inch <br /> To be connected to any adjacent driveway Pipe Yes ❑ No M <br /> DRAINAGE INLET REQUIRED Yes ❑ No EY <br /> Told Length: (with proposed) Total Number of Sly Duran Inlets <br /> Notes <br /> 3. HEADWALL Yes R No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Mm.Depth 3/4-A.B. <br /> Measuring Fed in length and Fed in width <br /> FEES <br /> Driveway Enaoachment Permit base fee............................$55.00 <br /> Feld Inspection <br /> ®Driveway w/or w/o pipe......... .._._.._.. ..._ .._ _..$95.00 ❑Paved fimtaga........_..........._..____$100.00+0.46fR <br /> ❑Drivewayw/boxCalvert...........................................$155.00 ❑ curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CounteAComputer,c:\Aroesa\Application for PermitslDriyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i 1 <br /> t. <br /> .�I <br />