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1. hear nefsue am react an me prommomm orms appticatioq and that the dmviption inchided inthis application are cor eot to the best of his/her - <br /> kmwlwdgg and <br /> 2. That he/she is the owner of tti a respective property,or is qualified to rgxeseot Bae owner,and <br /> 3..That he/she will assume fall responsibility for all liability for personal iojurq or damage to property which may arise out ofthe work described above, <br /> or which may arise out of hislher failure to do the work provided herein;and <br /> 4. That in the event any claim of such fiabBy is made against tbecouuty of San joagim or any deparhaeu,official or employee thereof he shall <br /> defend,inde=4 and hold6m end each of them hares for such claorg and <br /> S. That work shall be petfmwd by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County F=roadmaot Peun t;and <br /> 6. That if pemrission is granted as requested,he agrees to do the wo&desm''bed in a000rdance with all twins,oonditions and restriction ofthis and any <br /> attached sheet,' as I11 WavWons. <br /> tk- S-- 2- <br /> <p�' <br /> ofApplibmt-Tithe <br /> Daft <br /> FILED RMEMOR COAMWTS <br /> EXiS'1'll+i(}COND1TION$ <br /> L DRIVEWAY: Nene ❑ Pitt ❑ Gravel ❑ Agg gpte Base Q Paved(poor) ❑ payad(Good) <br /> 2. SLOPING: Awayfia nftvement Tow�aPavao <br /> rdsmot El_ <br /> 3: PIPES:. Nano ElESB-Type , r U Q k/ e <br /> Otherpipesinneigbboshoock Yes 9L No n Approaches Cross Drain ❑ Sim <br /> Ai4acaneat tondeAft% Yes ❑ No <br /> L <br /> 4.HEADWAL : Yea ❑ No' ' <br /> S.ASPHALT CONCRETI£DUM Yes ❑ No <br /> t~.BARREMS akegRigbi-of <br /> 9. DUCK Yea No ❑ If Yes;" V Style 2 Point ❑ Other ❑ Whdth Depth <br /> »>»>>>>?»»»»»»»»»»»»»»»PBRbffTREQU� <<««««««««««««S««««««< <br /> 1.DRIVEWAY: SFR COMMERCIAL. AC3RJU-MTLJJM ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Mho.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Lmumih of Pipe Requk9d:• Irl sad Diameter of Pipe —�--- inch <br /> To be connected to any adjacent driveway pipe Yea .No <br /> DRAMAt3E INE.ET REQUMED Yes ❑ No <br /> Total (with proposed) Total Number of Ste mm:Dri hkfa <br /> Notes <br /> 3. HEADWALL Yee ® No <br /> 4 PAVED FRONTAgE: PAVED with "Mm.Depth AC.over "Mm.Depth 3/4"AB <br /> Mpg Feet in k%&and Feat in width <br /> FEFS <br /> Driveway Encroachment Permit base fee........................ ..585. <br /> Feld Inspection <br /> Yw/or w/o pipe......... .. _. _S95 ❑Paved froa4aga _. _ . __ ___S100 00+0.46lR <br /> ❑Driveway w/box Culvert_..... _ S1S3.00 ❑Crr,( ,Sidetvallc..: SI00.tM+0.981ft <br /> Counte6computer,eMcoeaMpplicat on for PermilslDgyeway and Paved Fm,*p Page.2 of 2 Revised 8/2000. <br />