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illi.APYMS—A l t s'r L LD Y UJM IFiES: <br /> 1. That he/she has read all the provisions of this application,and that the desm*6on included mi fl&application we connct to the best of his/her <br /> knowhvdge;and <br /> 2. That he/she is the ovnw of the respective property,or is goaTfiedto represent theownesy and <br /> 3. That he/she will assume full responsibitily for all l>abiW.y 6orpasotni injru}+or daorage to propacty vvhicr may arise oat of the work dmmbed above, <br /> or which may arise out of hk&w failure to do the work provided haeia;and <br /> 4. That in the event any claim of such liability is made against%&County of San 7oagiun or my deparkmen,a fficid or employee thereof,he shall <br /> defend,indemnify and holdthem and each of them hamiless for soar clams;and <br /> 5. That work shall be peed by the appiica*and/or any representative of the applicant in the Cormty Right-of-Way at the above indicated site <br /> with a valid San Joaquin County FAunadynent Pemrit;and <br /> 6. That if pamimm is as requested,he agrees to do the wodr described in accordance with all tams,conditions and ra ttiction ofthis and any <br /> attached sheet,' as or special III provisions. <br /> --2 --�� <br /> ofApplicmfTitles Date <br /> FIELD INSPECTOR CO>MUM <br /> >>>>>>>>>EXISIM40 COMMONS«««««««««««««««««««« <br /> L DRIVEWAY: Ncae(r-p Out ❑ Gravel ❑ AMgpteBase ❑ Pa ) ❑ Pav*Good) ❑ <br /> 2. SLOPING: AwayRatr Pavement ❑ Towards Pavetrant ❑ Flat . <br /> 3. YVES:. Now Existing-Type �\ <br /> Othtrptpesmnergbbodtood Yes ❑ No Apptueches ❑ Crow Dram ❑ Sizer <br /> Attadmieat to pipe: Yea ❑ No <br /> 4.IMADWALL: Yes ❑ No' <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ Na <br /> 6..BARRIERS alwtgRight-c&Way <br /> 1. DrIrK Yes ❑ NoIfYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»>>>>>>>>>>»»>K>>> »»»»>PERLUTREQUII2EhMUS«««««««««««««««««««« <br /> 1.DRiVEWAY: SFR ❑ OOMMERCIAL ACsRtCUL INDUSTRIAL ❑ <br /> PAVED with 2- "Irvin A.C.over "� 3M" <br /> Depth �/ Dap'th A.B. <br /> NOW <br /> 2. PIPES: IA%*of Pipe Required:' Pt and Diama6er of Pipe Inch <br /> To be omnected to my adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea D No <br /> Tow (wi6 proper Total of Storm Drt&Inlets <br /> Notes <br /> 3. HEADWALL Yes ON No <br /> 4. PAVED FRONTAGE: PAVED with "WM Depth A.C.over "Ma Depth3/4"A.B. <br /> Measuring Feet is ten&and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee.................I S85.Oa <br /> Field Inspection <br /> Mveway W/or W/o pipe..... .. .. __... _ $95_ ❑Paved frartriga_ .__. __..__ 5100.00+0.46/& <br /> ov oway w/box Calvert ............ __.5155. ❑Curb,Gutta,Sidewallr_....._........._....5100.00+0.98/1t <br /> Catntm\Compitter,c:WocessV4plication for Petmits0riyeway and Paved Frontage Page.2 of 2 Revised.8/2000 <br />