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APPLICANT)�EREBYTM CERTIFIES: that the desiaiption inchrded in this application are correct to the best ofhis/her <br /> 1. That he/she has read all the <br /> proviaiorra oflhis atiOn,wd <br /> �whvdgc,and <br /> or is Vialifiedto re�sertthe owned smd <br /> 2. Tbat he/she is the owner of the respective P ', property which <br /> arise out ofthe work described above, <br /> 3. That he/she will assume full reapMali[ity faf all liability for personal <br /> wory_damage 10 or which may arise out of his4w failure to do the waic providedherein;Oand oTu ial Or employee thereof;he shall <br /> m the event any claim of such lisbibty is made agar the Courrty Of San Jbagiun or any deparimeeti, <br /> 4. That for such clsirrt;and <br /> defend,indema and hold them and each ofthem harmless -of-Wayatthe above indicated site <br /> 5, That work obeli be performed by the applicant and/or any epreseritative of the applicant in the Courdy Rigbt <br /> with a valid San Joaquia County Fam—cbn3at Permit;and ocnditims and rostnction of this and any <br /> 6. That if Pemvssion Wanted as"F"ted'he ams to do the work described in accordance with all terms, <br /> dad as special visions. <br /> Date� <br /> of Applicait-Title 7 <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXEsTI�1G CONDITIONS««««««««<<<<< «««««« <br /> 1. DRIVEWAY: None ❑ Dirt Gravel ❑ Aggregate Base ❑ Psved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away fromPavemmt 19 <br /> TowaidsPaveaueed ❑ Flat ❑ <br /> None ❑ Existing-TYPO /z 1 <br /> '5 Z--"I" <br /> 3. PIPES ❑ Cross Drain ❑ Size /2 K <br /> Other Pipes is neighborhood: Yes No ❑ APP vwh- <br /> Attachmei t to neighbor's pipe: Yes ❑ No <br /> 4, HEADWALL: Yes El No <br /> 5. ASPHALT CONCRETE D=: Yes El No <br /> 6.BARRIERS alaRrBbt of-Wa10'* Depth <br /> 7. DITCH <br /> Yes E] No ❑ Ifyes: V Style 2 Point ❑ Other ❑ Width <br /> »»»»»»»»»»»»»»»»»»»»PERMT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: <br /> COMMERCIAL F-1AORiCULTURE ❑ INDUSTRIAL El <br /> PAVED with <br /> "Min,Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> Ft and Diameter cf Pipe Inch <br /> 2. PIPLfx Length ofPipe R°q°'rod: —'_ <br /> ER <br /> To be comeeW to any adjaceat driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (whh propos Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "1vSn.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee......................e155.00 <br /> Field Inspection 5100.00+0.46/ft <br /> ❑ Driveway w/or w/o i ._.._ ❑Paved&mtaga.__..._.........._..:.._.... <br /> y pipe................................_. .$100.00+0.98/ft <br /> Driveway w/box(�ilvert...................... .. <br /> ❑C�rrb,Gutta,Sidewalk...................... <br /> Counter\Computes,c:\Access\Application for Permits�Driveway and Paved Frontage <br /> page 2 of 2 Revised 8/2000 <br />