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THE APPLICANT HEREBY CERTIFIES: <br /> I. That helshe has read alt the provisions of this application,and that the descripfim inanded ina&application am connct to the best of his/her <br /> knowtwdM and ` <br /> 2. '1'hat be/she is ibe owner of the respective property,or is qualified to represent the owaw,and <br /> 3. That helshe will assume full responsibility for'all liability for pers nal=jury or damage to property whwhmay arise oat ofthe work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any clai&ofsuch liability is made againstthoCowdy of San Joaqiun or any dam,official or employee flureo&he shall <br /> defend,indemnify and holdthem and each oftham harms for such clava and <br /> 5. That wait�sW�Abeby the applicaugt and/or any repres�tiVa of the applicant in the County RiO-cf Way at the above indieatted site <br /> with a va1'"roacliso dtPermit;end <br /> 6. That if p>ammis agrees to do the work described in accordance with all terms,conditions and restriction ofthis and any <br /> attached sheet, III provisions• <br /> Signature ofApplicati6Tiue Dam <br /> FIELD INSPECTOR CONMUM <br /> »»»»»»»»»»»»»»»»»}»»gXISTMOCONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ mitt Gravel ❑ Base ❑ Paved(poor) ❑ Paved(Good) El2. SLOPING: Awayfrons Pavamect ❑ Towanda Pave Flat ❑ <br /> 3: PIPES:, Nave Existing-Type <br /> Other pipes in nei0bod ood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attachment to nd&boes pipe: Yea ❑ No <br /> L IWADWAILL- Yes ❑ No <br /> S.ASPHALT CONCRETE ME, Yes ❑ No 41 <br /> (w.NARREMS ak"Rigbt-ofway <br /> 1. Bum Yes ❑ No IfYes: V Style ❑ 2 Point ❑ 011ier ❑ W"tdth Depth <br /> >»»>>>>>>»»»»»»»»»»»PERMITREQUIREMEM««««««««««««««««z«««< <br /> 1.DRIVEWAY. SFR.f COMMMCIAL ❑ /AGRtCVLTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "A in Depth AC,over K "A in.Depth 3/4"A E <br /> NOW <br /> 2. YIPS& L-g*of Pips Rap ko&' Ft and Dissaid r of Pipe ---� Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Tow Length: (with proposed) Total Noinber of Sborm Drain Iulefa <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC:.over "titin.Depth 3/4"AS. <br /> Measuring Feet in.length and Feet in width <br /> FEES <br /> Driveway Encroachn 3wit Permit base See................_.... ....5$5.00 <br /> Field Inspection <br /> way w/or w/o S100.00+0.46/ft <br /> Pips-....._....:...........__:...._..........-. S El 13t+entage...._.___.__......__.... <br /> ❑Driveway w/box(�rtveat._._.. _......._. ._.... .. S1Si.00 ❑Curb,Gutter,Sidewalk...:............_.....$100.00+0.9&ft <br /> Ceuntw\Computer,c:lAcce ssWpp ication for PennbMriyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />