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�, on are correct to the best of his/her <br /> .THE�pUCAN' BES`BY CERTHUS:G- and that the n �in appiicati <br /> I. That hehhehas read all theprovisions ofthis> °� <br /> know1wd1F0;and ,,Jifiedto repres-tithe owns;and <br /> of the respective PrOP"t3'oris which may arise out of-the work described above, <br /> 2.Thai helshe is the owner ys or damaSe to property <br /> ail liability far P Sm3 <br /> 3. That h"O will assume full respor> 3'oand of <br /> or which may arihe tial or employee thereof he shall <br /> arise 01111 ofhis/her failnse to do the wosic provided San kac*m or any <br /> 4. That in the event any claim of such halt is made for such claim;and <br /> and hold them and each ofthem ny ve of the applicant in the County RiS -of Way at the above indicated sits <br /> defend,indemnsfY lieaat and/orr aany r� <br /> 5. That workahall be performed by the app <br /> oacimest pest,and with au tom, �andrelt fiction of this and any <br /> with a valid San Joaquin ed as r to do the wosic d,,,iW in acccadance <br /> �� as requested,he agrees <br /> 6. That if Pemum gri d ar spm III provisions. -?n' <br /> attached dad �— <br /> ate <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COUNTS <br /> ONS«««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»EXiS'i'1rTG'CO ft Base ❑ Paved(poor) <br /> Dint ❑ paved(tsood) <br /> ❑ ❑ <br /> ❑ Gravel <br /> i. DRIVEWAY: None Flat <br /> Away from P.Ve ❑ TowardsPavement ❑ <br /> 2. SLOPING: <br /> 3.PIPES: None �E -Type ❑ Crass Dram ❑ Sm <br /> Yes ❑ No <br /> Otherpip�miOOd' <br /> AlUmfiuwd to ne'ghbor's pipe: <br /> Yes ❑ N- <br /> 4. HEADWALL: Yes ❑ No <br /> ip <br /> E DIKE: Yes tA No ❑ <br /> S. ASPHALT CONCRETE <br /> 6. aaRRI M aloe$Ri&-°f Way Other ❑ Width . Depth <br /> 7. DITCH <br /> Yes [INo V;. Ifyea: V Style EJ2 Point ❑ <br /> «««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTSAGRICULTURE ❑ INDUSTRIAL El <br /> SFR COM IERCIAL ❑ <br /> 1.DRIVEWAY: N hip.Depth 3/4"A.B. <br /> N Min.DepthA.G.over �_ <br /> PAVED with �— <br /> Notes <br /> Ft.and D►ametes cf Ape ��---" <br /> 2 PIPE& L.0 ofPipe Required: ❑ No <br /> to any adla�driveway Pipe Yes <br /> To be F-1 No <br /> DRAINAGE INLET REQUIRED (w propos <br /> Total Nmnber of Storm Drain I� <br /> Total 1=90Y <br /> Notes <br /> 3. HEADWALL Yes ® No N Nfm.Depth 3/4N AB. <br /> N Min.Depth AC.over __—_ <br /> 4. PAVED FRONTAGE: PAVED with eet in imgth Feet in width <br /> Measuring <br /> FEES <br /> Driveway Encroacbwed Penn it base fee........................ ..$85.00 <br /> $100.00+0.4618 <br /> Field h>spect<on $95.01) Paved frontage..--....._.-•..._............ $lOD.00+0.98/ft <br /> ❑ Driveway w/or w/o pipe•.........................._.......-•-..........$l 5.00 E]Curb, <br /> Gutter,Sidewalk•...................... <br /> .......- \Driveway Revised 8/2000 <br /> ❑Driveway w/box Cttivest•..:............. Page 2 of 2 <br /> lication for Permits and Paved Frontage <br /> Cou�ComPutar,c: SPP . <br />