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THE APPLICANT HEREBY CERTIFIES: , <br /> 1. That he/sW has read all the provisiaos of this app&dio%and gist the description included ie*is application ace coaect to the bast of his/her <br /> knowlvedge;and <br /> 2. That helshe is the owner of the respective property,or is gw Medto resent dw ownu r,and <br /> 3. That ho(she will assume full responalifity for all tiAMW for personal inoyordamage to property whirl:may arise out ofthe work desmbed above, <br /> or which may arise out of his/hers failwre to do the work pmvided herein;and <br /> 4. Tbat in tho event any claim of such liability is made against ffieCounly of Sam magiva or any deperkam t,official or e thereof he shall <br /> defend,indemnify and holdthem and each of thein WnAew for such daiin;and <br /> 5. That work shall be peaked by the applicant and/or any representative ofthe applicant in the County Right.-of-Way at the above indicated site <br /> with a valid San Joaquin County Faaoati mai t PecwA and <br /> S. That if peamissiaai is to do the wo&dwmi)ed in scoccdance with an temsa,conditions and restriction ofgiis and any <br /> aftached or apecxal ffi <br /> SignatureofApplicast-Title Date <br /> FIELD INSPECTOR COAQdENTS <br /> »»»»»»»»»»»»»»»» »»>OaSTI NGCONDTIIONS««««««««««««««t«««««< <br /> 1. DRIVEWAY: None fat ❑ Qavd Aaregaft Base ❑ Pavokpeer) ❑ Paved(Good) ❑ <br /> Z. "PING: Awayfsum PaveMsseot ❑ Towards PsvesmoM Flat ❑ <br /> 3: PIPES• Now Existing-Typo <br /> Other pipesinnoigbbodmd: Yes ❑ No Approaches ❑ Croas Drain ❑ Size L�—J <br /> Attachment to nein is pipe Yea ❑ No <br /> 4. 11Et1DWAI,L: Yea ❑ No <br /> S. ASPHALT CONCRETB DUM. Yes ❑ No 4� <br /> G.BARRIERS akngftbt-ofWay <br /> 7. DITCH Yea ❑ No IfYea: V Style ❑ 2 Pout Q Other Q Wad& Depth <br /> »»»»»»»»»»»»»»»»»» <br /> PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL Q AGRICULTURE ❑ INDUSTRIAL. ❑ <br /> PAVED with 1 "Mie.Dep&A.C.over T "1bIm.Dep&3/4"A.& <br /> Notes _. <br /> 2. PIPER: I.angth ofPipe Required:- A and Dixemsor of Pipe Inch <br /> To be connected to any a4ac ait driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> TOW Length: (with proposed) Total Number of Stores Drain Islets <br /> Notes <br /> 3. EMADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Dopgs A.C.over "Min.Dep1h3/4"A.B. <br /> Measuring Feet in lmg&and Foet in wid& <br /> FEES <br /> Driveway Fnaoacbmeat Pemsit base fee..................... ..... 5. <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe..._..... .._. ... ....._$95.90 ❑Pavedfroatage.._. <br /> ❑Driveway w/box Culvaat. ._.. _ _.._.... _ $155.00 ,Gutta,Sidewalk.................... 00 .9 <br /> Cou>rterkComputer,c:lAccesslAppliemfion for PermitslDriv y and Paved Frontage Page.2 of 2 Revised 8!2000 <br />