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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provWons of this apphen ioq and that the description included in this . <br /> knowlwdge;and aPPl�on are correct to the best of his/her <br /> 2. That hdahe is the owner ofthe respective property,or is qualified to e'd the owner;and <br /> 3. That he/she will assume fill re spons<'bt'td'y to,all liaL itjr far paaouai urjwy a to <br /> Of which a F'Ope 'whidi may arise out of ttx work des. d above, <br /> may arise out of his/her fiu'lare to do the work providW herein;and <br /> 4. Tbat in the event any claim of such liability is made against the County of San Joagiun or any department,official� to <br /> defen(,indemnify and hold them and each ofthem harmless for an&clam and � Yen��he shall <br /> 5. That work shall be performed by the applicant and/or any rep"weatat ve ofthe applicant is the County Rigbt-of--Way at the above indicated site <br /> With a valid San Joaquin Cou*EnmVechment pemf,4 and <br /> 6. That if permission is as requested,he to do <br /> - 'Win accordance with all terns,omdifions a�restriction e>t'this dna any <br /> attached <br /> am �t m� <br /> S*Ah- I U <br /> Date <br /> FIELD INSPECTOR COMMEPNTS <br /> >»>»»'>>»>»>�»>>>>'»»»>>»»»»EXISTING CONDITIONS««C«<<<<<<««««««««««< <br /> [2. <br /> DRIVEWAY: None Dirt ❑ Graved ❑ Aggregate Base ❑ Paved(d�) ❑ Paved(Good) ❑ <br /> SLOPING.- Awayfrom Pavement {e Towards Pavement ❑ Flat <br /> 3. PIPES: None g-Tye Q <br /> Other pipes in WW*arhood- Yea ❑ No 13' Approaches ❑ Cross Drain ❑ S,, <br /> Attaderrent to neismoes pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No K <br /> & ASPHALT CONCRETE DACE: Yes ❑ No ( <br /> 6. BARRIERS alon8 Rigbt-af--Way <br /> _ N/p <br /> 7. DITCH Yea ❑ No Dq Ifyes V Style ❑ 2 Point <br /> Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMU <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICMTURE <br /> ❑ INDUSTRIAL ❑ <br /> PAVED with ,�' "Min.Depth A.C.over " <br /> Notes Mie Depth 3/4 A.B.N <br /> 2.PIPE& Length of Pipe Required: Pt.and Diameter or pipe Inch <br /> To be connected to my adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: —_(with prodoeed) Total Numb of Storm Dni Injela <br /> Notes <br /> 3. KFADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Mia Depth A.C.over "Mia Depth 3/4"A.B. <br /> Ming Feet in length and Fed in width <br /> FEES <br /> Driveway Enc oadmxat Permit base flee..........................:585.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe........................._....._...._. _..595.00 <br /> ❑ ._._ __.5100.00 <br /> - ElDrivewayw/boxCulveri........................ .. ...S1S5.00 <br /> Paved fioutag..,..... +0.46/R <br /> _....._. _. ❑Curb,Gutter,S' <br /> Cou'a'a'Co-P-1-1 c:kAeeeaslApplication for P�mitalDriveuvay and paved Frontage <br /> Page 2 oft Revised 8/2000 <br />