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THE APPLICANT HEREBY CERTIFIES: r <br /> 1. That he/she las read all the provisions of this app tion,and that the dmet*dm kcbded iethis application are correct to the beat of his/her <br /> knowlvadge;and <br /> 2. 'That he/she is the owner of the respective property,or is qualified to rgWment fire owner and <br /> 3. That he/she will assume full reqnnsibifity for all tishirdy for personal 4uryordauiage to property whichmay arise oat oftlm work described above, <br /> or which may arise out of his/her failnne to do the wont provided heaein;and <br /> 4. That in the event any claim of such fiabil¢.y is made againd*&County ofSan]bacprra of any,depwbnen%ofLciat or employee the e4 he shall <br /> de&nd,indemnify and holdthem and each ofthem harmless for such claire;and <br /> S. That work shalt be padmled by the applicant ardor any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Eaaoadkneot Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the mark described in aoomhum wills an <br /> tears,oonditicos and restriction of this and any <br /> attached a adudet}e rat iii provisions <br /> sigratae Trite Date <br /> FEUD INSPECTOR C01MAUNTS <br /> »»»»»»»»»»»»»»»»»»»»F.XiSTRg000NDMONS«««««««««««««««««««« <br /> } <br /> L DRIVEWAY: Nose / Die ❑ Ghavoel ❑ Aggrm9micBase, ❑ Paved(poor) p Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavamau p Towards Pavemeut fg�- Flat p <br /> 3.' PIPES:. Now E _Zype <br /> Other t innaWkodmod: Yes ❑ No Approaches ❑ Cross Drain ❑ Srze <br /> At<admieotto Yea ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S.ASPI#ALT CONCRETE Dna: Yes ❑ No-4K-� <br /> 6..BARRIERS along Burt-cff Way <br /> 1. DITCH Yes El NO M-�IfYea: V Style p 2 Fbiot p O&w p Width Depth <br /> »>PERMITREQUIItE1dENTS«««««««««««««««««<c«<< <br /> 1_DRIV&WAY: SFR COMME1tCIAI. ❑ A0111 ,ULTURk ❑ INDUSTRIAL p <br /> PAVED with Z "A&L Depth AC.over Af "Ism.Depth 3/4"A.B. <br /> Notes ^�5 �D /•2 YyldYt2 ��C, <br /> 2. PEM& Length of Pipe RecNko&' Pt.and Diameter of Pipe Inch <br /> To be oomected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> TOW (w proposed) Total Noumber of Stosan Drafa Ialefa <br /> Nater <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.ova "Mia Depth 31V A.R <br /> Mpg Feet in tenth and Feet in width <br /> FEES <br /> Driveway Fna0whineat Pecink base free........................ ..585. <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.. ._.. ..... ..__ . _595.90 Awl <br /> a _.__......_........_....5100.00+0.46/R <br /> F-1 . 100 <br /> Gutta, <br /> Counter\Computer,cAAccesslApplication for Pe[mitsl dymay and Paved Froze Page.2 of 2 Revised=000 <br />