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THE APPLICANT HEREBY CERTHUS: <br /> 1. That he/she hes read all the provisions of this aplffitatioa,and that mthss application are corred to the best of his/her <br /> knowhvdge;and <br /> 2. That he/she is the owner of the rive property,or is qualified to represent the owne,and <br /> 3. That here will assume fall responsibiUy for all liability Aw personal injury or damage to property wluchmay arise out oftbe 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 claim of such liabiMy is made against the County of San kaon or any department,official or employee there4 he shall <br /> defend,indemnify and hold them and each of them harmless for such clam and <br /> S. That work shall be performed by the applicant and/or any rave of the applicant in the County Rig&-of-Way at the above indicated site <br /> with a valid San Joaquin County Facaoadrment Permit;and <br /> 6. That if permission is granted as re ed;1r " mai wade descdbad in accordance with all temta,conditions and restrictim offhis and any <br /> attached sheet,included asij epe' is <br /> Trite Date <br /> FIELD INSPECTOR COINS <br /> »»»»»»»»»»»»»»»»>}» -EXISTIMCONDMONg«««««««««««««««««««« <br /> 1. nRVEWAY: Now ❑ Dirt ❑ Gravel Aggregate Base ❑ Pavokpow) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavemat � Towards Pavan n t ❑ Flat ❑ <br /> 3. PIPES: Now ❑ Elost*-Typo <br /> Other pipes inneighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Sze L—�J <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4.HEADWAId.: Yes ❑ No <br /> S.ASPSALT CONCRLTE D=:' Yea [] No <br /> 6. BARRIERS ak"Ri&-o&Way <br /> 1. DITCH Yes &!-No ❑ IfYes: V We 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»» <br /> PERMIT REQUIREMENTS««««««««««««««««z««<<< <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 14k.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Longfh of Pipe Required: FL and Diameter cf Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total length: (with proposed) Total Number of Stmt Drain Inlata <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in teff0h.and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base five........................... <br /> on <br /> away w/or w/o pipe......... . ._.._ _ 595. ❑Paved finutaga.._......_.___._..__....$100.00+0.46/ft <br /> ❑Drivewayw/box(timlveat._. .. .._........_.._._... .... .. 155.00 ❑Corin,Gutter,Sidewalk......_...............$100.00+0.98/R <br /> CountaiComputer,c:lAccess\Application for PermitslDriveway and Paved Fringe Page.2 of 2 Rued 8/2000 <br /> i <br />