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TILE APPLICANT HEREBY CERTIFIES: F <br /> 1. That he/she las mead alt the provisions of this application,and that the description kchW ed Mathis application are correct to the best of his/her <br /> knowhvdge;and <br /> 2. That he/she is the owner of the respective property,or is gwMedto represent the owne,and <br /> 3. That he/she will assume full respo ity f-all Lability for personal injury or damage to property which may seise out cfthe work descxibed above, . <br /> or which may arise outofhis4ff M=to do the workptovidedhereio;and <br /> 4. That in the event any claim of such liability is made against tfeeCounty of San anagiun or any depmr meat,official or employee thereof;he shall <br /> defend,indemnify and hold&=and each of them W=Aeea for such claim;and <br /> 5. That work shall be peaformed by the applicant and/or any reprove of The applicant in the County Rigldof-Way at the above indicated site <br /> with a valid San Joaquin County Faanachnae t Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the wodc desrn'bad in accordance with alt terms,omditims and restrictian ofthis and any, <br /> attached sheet,' as general III provisions. <br /> M4.rhIl <br /> SignatreofAMB-A Tide 'r"11n4e40-;4j. Date <br /> FIELD INSPECTOR C011 ONTS <br /> EXISIM40 CONDITIONS««z«««««««««««««««««< <br /> L DRftWAY: None ❑ UiWt ❑ Gravd ❑ Agpq;ateBase ❑ Paved(pw) ❑ Paved(Good) <br /> 2. SLOPING: Away froom Pavement ❑ Towards Pavammmt ❑ Flat <br /> 3., PIPES: Now ❑ Em&ft-Type <br /> Other in ' Yes No Cross Drain ❑ Size <br /> Prem � APproec7res <br /> Attadmxnt to s pipe: Yes o ❑ <br /> 4.HEADWALL: Yes ❑ No <br /> ASPHALT CONCRETE DIKE: Yea ❑ Na <br /> 6..R4RRlERS along Right-af Way <br /> 1. Drrcx Yes X-190 ❑ lfyea: V Style int ❑ Othw ❑ W-W& Depth <br /> »»>>>>> »»»»»»»»>,»>PEROXQUIREMENIS«««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑. COMMERCL4L AGRICULTURE ❑ INDUSTRIAL <br /> PAVED with Z "Min.Depth A.C.over Mm.Depth 3/4"A.B. <br /> Nota <br /> 2. PIPE& Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjwat ddmw ay pipe Yes �!No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Totssl Length: (with Proposed) Total Number of Storm Drsht Islets <br /> Nates <br /> 3. HEADWALL Yes Mn No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "Mm.Depth 3/4"AB. <br /> Measuring Feet k length and Feet in width <br /> FEES <br /> Driveway Eamoachnw t Permit base fee...........................$95. <br /> 1 Id En5wfion <br /> ' awayw/orw/o pipe............: $9 - ❑Paved +0.46/R <br /> ❑Driveway w/box Cmtvat._.._.___......__..__... ... _..$1 .00 ❑Curb,Qulker,SidcwaJk..:.. .. ... ...5140.00+0.98fR <br /> CountalCommputer,cMccess\APplication for PenndslDriyeway and Paved Fi or tW Page.2 of 2 Revised 8/2000 <br />