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THE APPLICANT HEREBY CERTIFIES: <br /> 1. Tbd he/sbe has read aH the provisions of this sppLcatioor and that the demarkmi a included is this applic atim ace owed to the best of his/her <br /> koowl wlge;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 toll responembility for all bdmTty For personal injury or dunage to property whirl may arise out of the work desmbed above, <br /> or which may rise oat of biilher hilum to do the work provided herauq and <br /> 4. Thatis the event say claim of moth habay is made against the Coosty of Sao loagicm or any depactoaeal,o8icW or esuploym thaeot be shall <br /> defend,rods*and hold them mud each of them harmless for such cbkiq and <br /> 3. That work shall be peafocmed by the appiiamt and/or say representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Fmeachmeut Pemsit and <br /> 6. That if permission is graded as he agrees to do the work described in aooadaooe with a!l tams,conditions and raahidim of this and any <br /> atncbea a,genesl III ens _ <br /> -� <br /> Signature of Apphamat-Title Date <br /> FIELD INSPECTOR COMAMM <br /> »»»»»»»»»»»»»»»»»»»»PJQb'IM CONDITIONS«««««««««««««««««««« <br /> L DRFVMAY: Nom ❑ Dirt � Gravel ❑ AmegeteBaas ❑ Paved(poar) ❑ Paved(Good) <br /> 2.SLOPING: Away fmm Pavement ❑ Towards Pavan" ❑ Flat ❑ <br /> 3. PUSS: Now tg� Eridiag-Type <br /> Other pipes in naghimhood: Yes ❑ No <br /> n—AppreacLes ❑ Goes Dain El Size <br /> Adarhmed to migbbor9 pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No' .4 <br /> S.ASPHALT CONCRETE D17CS: Yes ❑ No <br /> ev- <br /> 6- BARRIERS along RW-c&Wsy <br /> 7. DITCH Yes ❑ No X— If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»>>>>> »»»»»»»»»»PERLUT REQU REAM TS«««««««««««««««««««« <br /> L DRIVEWAY: SFR COMMERCIAL ❑ AGRkS MMI ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Min.Depth A.C.over � "Min.Depth 3/4"A B. <br /> Nates <br /> 2. PIPS& Leooh of Ape Required: Pt.and DRanksb r of Ape Inch <br /> To be connected to any adjaoeat driveway pipe Yes ❑ No Fg:-- <br /> DRAINAGE INLET REQUIRED Yes ❑ No AWL <br /> TOW Length (with proposed) Tota{Nosier of Staastt Drsda Liefs <br /> Notes <br /> 3. HEADWALL Yes No <br /> d PAVED FRONTAGE: PAVED with "Era Depth A.C.over "Ma Depth 3/4"A.B. <br /> mmmiug Fed in taegiih and Fed in width <br /> FEES <br /> Driveway Fnaoachmmt Permit base fee <br /> ................_......t... S. <br /> MeeLdd Impecstion <br /> � <br /> I��`.u+tveway w/or w/o pip&........._.__._.— _ _ _� ❑Pavad 5100.00+0.46/@ <br /> ❑ Driveway w/boz CahaR. ._ ___..... _..._....._..5133.00 ❑Curb,t3utter,SwawalL.._.._..............$100.00+0.98/R <br /> CcuatakCamputar,cAAwmL4Vp1iodim for Par msWDrivomy and Paved Frontage Page 2 cf 2 Revised 8/2000 <br /> i <br /> i • <br />