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THE APPLICANT HLKLBY CERTIFIES: <br /> 1. That he/slte has read all the provisions of this application,and that the deso4 tion included Mi thin application are corn t to the best of his/her <br /> knowWge;and ;z . <br /> 2. That he/she is the owner of the respective properly,or is qualifiedto represent theownw,and <br /> 3. That he/she will assume full responsibility for all liability forpeiscaai injury or damage toproperty which may arise out of the wodc 'bed above, <br /> or which may arise out ofhis&w failure to do the work provided havin,and <br /> 4. That in the event aw claim of such liability is made against 46eCo n ly of Sera kmqkm or any departumt,official or employee lhere4 he shall <br /> defmd,indeumify and holdthem and each of them hamulosa for so&clang and <br /> S. That work shall be perfarmed by the applicant and/or any representative of the applicant in the Couuty Rigg-of-Way at the above indicated site <br /> with a valid San Joaquin County Fncroedaat Peunit,and <br /> 6. That if permission is gauted as requested,he agrees to do the work descubed in accordance wir all terms,conditions and testridion of any <br /> attached sheet,included as eine pecialli> owsro , <br /> Sigmteu+e of \\We Date <br /> HEIM INSPECTOR COMM$NTS <br /> »»»»»»»»»»»»»»»»»»»»EXISIMgo CONDMONS«««««««««««««««««««« <br /> L DRIVEWAY: Now ❑ Dat [] Gkavel ❑ Aggregate Mase ❑ Pavod(poor) ❑ Paved(Good) <br /> 2. SLOPING: AwayfivmPavamam ❑ TowardsPavemaot ❑ Flat <br /> 3: PIPES: No- i Eids ft-Type <br /> Otharpipesinn*W dm& Yes ❑ No Er Appreechas Q Crass Drain ❑ Size �] <br /> Attachment to neaghbor"a pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE Yea ❑ No <br /> 6..BARRIERS along Pj*-of Way <br /> 1. DITCH Yes ❑ No V if yes:- V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »>>> ?>>PF- TRFQL7>R NTS<z«««««««««««««««z«««< <br /> 1.]DRIVEWAY: SFR ❑ WMMERCIAL At3RkMTIJItE ❑ DMUSTRUL ❑ <br /> PAVED withy. . "11fia.Depth A.C.over "hfm.Depth 3/4"AR <br /> Nates <br /> 2. MPE& Leugth of Pipe Regaa*d: Ft.and Diameter of Pipe Inch <br /> Tobe connected to any adjacent driVaway pip* Yes ❑ No <br /> DRAINAGE INLET REQUMD Yes ❑ No 4ff— vv <br /> Tats (-Aproposed) Tota{Number of$buraz Drda bdefa. <br /> Nates <br /> 3. HFIIDWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mia.Depth AC.over "hfm.Depth 3/4"A.B. <br /> Mpg Feet in teng1h and Feet in width <br /> FEES <br /> Driveway hwrftchmeat Permit base fee.......................... 5. <br /> Fel 'on <br /> jVK <br /> EhDriveway w/or w/o pipe.......... _. . _. S9S_ ❑Paved frvntage--...-......_......___,$100.00+0.46/ft <br /> kmway w/box Calvet._.._. _. _...._ S1S3.00 ❑Curt►,Gutter,Sidewalk......................$100.00+0.98/ft <br /> CounterkCompute,c:lAccesatApplieation for PermhMDriyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> ,1 <br />