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'fills;A rrJ1AUALNX fMKL*Y UILKIM'LLS: <br /> 1. That he/she has read all the provid(m of this application,and that the descxiptioat included kais application ate correc t to the best of his/her <br /> knowWge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represeut the owner;and <br /> 3. That he/she will ate,m full responwhility far all hAffity for personal injury ordamage to p vpmdy which may,arise out ofthe work described above, <br /> or which may arise out of hu&w failure to do the work provided hereto;and <br /> 4. That in the event any claim of such liability is made against the County of Sau Joacyi m or any dqwkmmk official or <br /> employee thereof be shall <br /> defend,indemnify and holddmm and each of than harmless for such claim and <br /> 5. That work shah be pmfacmed by the applicant and/or say ropsese tative of t'he applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroac)nmont pewit;and <br /> 6. That if pe a&don is graded as requested,he agrees to do the wade described in acaardance with all temna,eoeditiam and restriction.ofthis and any <br /> attached sheet,mduded as general or special III provisions. <br /> SignstumofApphcaot-Tithe Daft <br /> FIELD INSPECTOR C 0AEMWM <br /> »»»»»»»»»»»»»»»»»»»»EXISTING C©NDMONS«««««««««««««««««««« <br /> y <br /> L DRIVEWAY: None Out ❑ Oravai ❑ Aggregate Dasa ❑ Paved(pow) ❑ Paved(Good) <br /> 2. SLOPING: Awayf--Pavement Towau&Pavaamad ❑ Flat ❑ <br /> 3: PIPES: Now ❑ Esietutg-Type 12 2 d��v a uJ 4 jcS <br /> Othw Pipes in neigl*odmd: Yes ( No ❑ Approaches Q Croas Drain ❑ Size <br /> Attadrmmt to ndghbola P+pa Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETED Yes ❑ No (� <br /> 6..BARRIERS along Right-of-Way &1A <br /> 1. DiITCH Yes 10 No ❑ Yves: V Style 02'2 Paid p Other ❑ Width Depth <br /> >>>>>>>>>>>» PFRMITREQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AC3RICULTU" ❑ INDUSTRIAL ❑ <br /> PAVED with Z "fin Depth AC.over 4 "Mm.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& Lem of Pipe R"Orod:' Pt,and Diamater of pipe inch <br /> To be connected to any adjacad driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> TOW Laug&I (_mProposed) Total Nma6er of Store Drorm haiefa <br /> Nates <br /> 3. EMADWALL Yea ® No <br /> 4. PAVED FRONTAGE: PAVED with "Wm Depth A.C.over "Mm Dopflr 3/4"A.B. <br /> M-curing Fed in kuglh and Feet in width <br /> FEES <br /> Driveway Encaoacbmed Parmit base fee............................585.00 <br /> Field hmpection <br /> ❑Driveway w/or w/o pipe._______ .._...$95.00 ❑Paved traatage. _. _ ..__ Si00.00+0.46/& <br /> ❑Driveway w/box culvert._....................... ... .... _.$155.00 ❑Crub,(runt,Sidewalk.........._...._.....$100.00+0.98/ft <br /> CmdelACompirter,o:V-cessWpplioation for Permjtj yeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />