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THE APPLICANT HEREBY CERTIFIES: <br /> I. Thai he/she lens read alt the provisiorms of this appation,and drat the description iochtded iutLis application <br /> an cord to the bast of his/hes <br /> knowlwdge,and <br /> 2. That he/she is the owner of the respective property,or is qualified to rpt the owner and <br /> 3. That he/she will assume full responsibility for all y forpersonai miury or damage to property whichmay arise out ofthe work described above, <br /> or which nay arise out of his/her failure to do the wait ptnvided hetein,and <br /> 4. That m the event any claim of such liability is made against the Coamty of Sao <br /> Joaqim or imY deparbuent,afficial or employee thereat he shall <br /> defend,indemnify and hold them and each of them hamilesa for sole claim aced <br /> 5. That wait shall be perffamed by the aMhc a*and/or any representative of&ecant in the <br /> appli eawEdy xigit-of-way at the alwvo indicated site <br /> with a valid San Joaquin County Eft Pew and <br /> b. That if permission is granted as requested,he agrees to do the wort described in accotdanoe with ail teres,conditions and restriction ofthis and any <br /> aitached sheet,included as or visions. <br /> SigmefteofApplicami-Tifle Dam <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXIS11NO CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dict n Gravel ❑ AgueBase ❑ Pavod(poor) ❑ Paved(Good) ❑ <br /> 3.SLOPING: Away from Pavement ❑ Towards Pavemant Flat ❑ <br /> 3. PIPES• None � Existing-Type <br /> X01 pipes i►neig*odwod- Yes ❑ No Approaches ❑ cross Drain ❑ Sim <br /> Affachment to neighbor's Pipe: Yes ❑ No <br /> 4.HEADWALL: Yea ❑ No <br /> S.ASPSALT CONCRETE DIItL►:' Yes ❑ No <br /> 6..BARRIERS along R.igbt-cf-Way <br /> 1. DITCH Yea ❑ No IfYes: V We ❑ 2 Point ❑ Other ❑ Widen Depth <br /> ;V>>>>>>>>>>>>>>>>PPRMTREQLMLEMENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMhdERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 1i "Man Depth A.C.over 4 "Min.Depde 3/4"A.B. <br /> Nates <br /> dlpMir, �a <br /> 2. PIPE& La**of Pipe Repaired: Pt.and Diarww cf Pipe Inch <br /> To be connected to any Miaaat driveway pipe Yea, ❑ No J <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> T'ohtl Length (with proposed) Total Number of Sturm Drale we" <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4 PAVED FRONTAGE: PAVED widen "Win Depth A.C.over "h4in.Depth 3/4"AB. <br /> Mpg Fed is leng&and Feet in width <br /> FEES <br /> Driveway Buroachmemt Permit base fee.......................... <br /> FieldLnspection <br /> syw/orW/o pipe............:.._._._._._..._... tSgg_{1g' <br /> ElPaved fr+aotage..._..._....__.._.._._....S100.00+0.46/& <br /> ElDriveway w/bomt Culvert....................._.._..................$155.00 ❑Curb,Gutter,Sidewalk...:.. .. ..... ....5100:00+0.98/ft <br /> CouZltalCcmputer,c:WccesslApplioation for PemritslDriveway and Paved Fmntaga Page.2 of 2 Revised 8/2000 <br /> 3 <br />