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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she hes read all the provisions of this application,and that the descriptio©inchaded in ibis application are correct to the best of his/her <br /> knowhvdge;and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent the owrer,and <br /> 3. That he/she will assume full responsibility for all liability forpersonai injury or damage to property which may arise out ofthe 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 the County of Saar Joaq;iun or any depertment,official or enVloyee thea 4 he shall <br /> defend,indemnify and hold 6=and each of them harmless for sack clang 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 County Event Permit;and <br /> b. That if permission is granted as requested,he agrees to do the wank described is accordance with all tears,000ditions and restriction of this and any <br /> tract rt as gmerai or•special ons. <br /> 6V 0-2,//i/d,� <br /> Signature ofAppficau1,-TMe Date <br /> FIELD INSPECTOR COMPA ENTS <br /> »»»»»»»»»»»»»»»»»»»»ENISTING CONDITIONS«««««««««««««««««««« <br /> y <br /> L DRftWAY: None Dot ❑ (ravel Awvgaft Base ❑ Paved(poor) ❑ Paved(Oood) ❑ <br /> 2. SLOPING: Awayfrom Pavament ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Now Exist g-Type <br /> Other piles in nd0bodod Yes ❑ No ❑ Approaches ❑ Cross Drain ❑ Size C� <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4.HEADWALL: Yes ❑ No ❑C <br /> S ASPEtALT CONCRETE DIKE:' Yes ❑ No <RJ <br /> 6..RARREERS alomgRi&-cMay <br /> 7. DITCH Yes 9 No ❑ IfYes: V We 2 P..d ❑ Other ❑ Width Depth <br /> »>»»»>»»»»»»»»»»»»»»»PERMIT REQUIRE)MM«««««««««««««««««««« <br /> I.DREV WAY: SFR C COMMERCIAL. ❑ ACsR)CtJI,TiJRE ❑ INDUSTRIAL. ❑ <br /> PAVED with Z "Mia.Depth AC.over _"Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& L-g*of Pipe R-pier Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINA.OE INLET REQUIRED Yes ❑ No <br /> Total (-M prop08ed) Total Number of St area Drain Inkla <br /> Notes <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED withkfm <br /> " Depth A.C.over "Mm.Depth 3/4"AB. <br /> Mpg Feet in leng4h and Feet in width <br /> FEES <br /> Driveway End Permit base fee............................585.00 <br /> Field Inspection <br /> ®Driveway w/or w/o pipe.........._..._._.._. _595.40 ❑Paved <br /> ......._. fi+oataga.._...._....__.......__....5100.00+0.46/ft <br /> ❑Drivewayw/boxCmlveat._.. . _........ _.. _............_..S1SS.00 ❑curb,outter,Sidewalk.......................5T00.W+0.9&U <br /> C mterlComputw,c:l=MAVI n for Painds0riveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> f <br />