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•111-IS ArrJA :A N 1 IMKL+tS Y UAKlIN Mw <br /> 1. That he/she hes read all the proviskms of this appHcdio%and that the description in hided is this applicadon are correct to the bast of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owBjy and <br /> 3. That he/she will assume fall respomlility for all liability fir personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out ofhis/Iw failure to do the warm provided herein;and <br /> 4. That in the event any claim of such liability is made against go County of San hragkm of aay depertme4 a ffidd or eaiployee thereog he shall <br /> defend,indemnify and holditm and each of them harmless for sods Clain;and <br /> 5. That work shall be pedmmed by the applicant and/or any rapresentgtivs of&e applicant in the County Rigbi-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if pemrission is granted as requas!ed,he agrees to do the wodc described in acambwe with all temm,omdifiom and restriction of this and any <br /> ineiuded as gemaaf err <br /> SigostnreofAppTitles Dam <br /> FIELD INSPECTOR.COMM XM <br /> »»»»»»»»»»»»»»»»»»»»EXMT gGCONDMONS««r«««««««««««««««««< <br /> L DRftWAY: None Digit ❑ Gravel ❑ Aggregate Base ❑ Paved(pear) ❑ Pav*Good) ❑ <br /> 2. SLOPING. Aunyfrom Paves Towanda Pawment ❑ Flat ❑ <br /> 3. pins- None [� E _Type <br /> Odker Pipes inneigbbarhood: Yes No ❑ Approaches [] Cross Drain ❑ Size <br /> Attachment to naghbot'slupe: Yes ❑ No <br /> 4.HEADWALL.: Yes ❑ No' <br /> S.ASPI#ALT CONCRETE DUAM Yes ❑ No . <br /> G.BARRUMS a1ogg Rigbt-a7Nd <br /> 7. DITCH Yes ❑ Ifyes: V Style At2Pbwt ❑ Other ❑ Wrdth Depth <br /> PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRfCMTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth A.C.over "ldm.Depth 3/4"A.B. <br /> Nater <br /> 2. PIPM Length of Pipe Regoirak Pt.and Diameter of Pipe Inch <br /> To be connected to any adjacart driveway pipe Yea No , _— <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total (with proposed) Total Number of Storer Drata bdets <br /> Noter <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "M'm.Depth AC.over "Mi.Depth 3/4"A.B. <br /> Mpg Fent in tenglh and Feet in width <br /> FEES <br /> Driveway Fnaoac)iment Pmmit base free......................... .00 <br /> Field Inspection <br /> away w/or w/o pipe......._ .. ._ .._ _.. _595.(!0 ❑Paved&mtaga _ » ____ 5100 00+0.46/ft <br /> ❑Drivowayw/boz Calvark._._. _... . :...__.. ....__ S1S3.00 ❑Curb,Clutter,Sidewalk..............._.....$100.00+0.98/tt <br /> CounteAComputer,c:lAccew\Apphcation for Panift0rimmy and Paved Frontage Page.2 cf 2 Revised 8/2000 <br />