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APPLICANT REREBY CERTIFIES=�that the d ��d n tWs application are correct to the best of his/her a <br /> I Tbat he/she has read all the provisions ofthis <br /> knowlwdge or is qualifiedto the owr and <br /> 2. That he/she is the owner of the respective property, Y PrO�'whi&m'Y arise of the work described above, <br /> g, That helshe will assume full rebs'far all liabr+<Y <br /> fp <br /> or whichMay arise out of his/her'failure to do the waric provided herein;and �6cial or anPloYee �he shall <br /> 4 That in the event any claim of such liability is made against <br /> the Courtly of San or say <br /> d each cifthem harmless ler such claim; ft-of way at the above indicated site <br /> defend,inderonify and hold them anof the applicant in*a County Rig> <br /> 5. That`work shell be Performed by the applicant and/or any�*e <br /> F 8 t P a conditions and restriction of this and any <br /> with a valid San Joaquin Courtly to do the work described in accedence with all temps, <br /> 6. That if permission is granted as requester he agrees <br /> attached sheet,included as genes <br /> or spm III provisions. R 1 <br /> ,.c Date <br /> Sigoat=of APp -Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»» ........... ««« <br /> ESi� COMMONS««««««««<<< <br /> pave3(poor) El paved(Good) ❑ <br /> 1. DRIVEWAY: None ❑ Dirt Grave; ❑ �ease ❑ Flat2. SLOPING: 10 <br /> Away from Pavemect ❑ Tows Pavement E) <br /> 3. PIPES' None Existing-Type ❑ Cross Drain ❑ Size <br /> Yes El No APPS <br /> Other pipes m neighborhood: <br /> meat to n ig%Wg PiPe: Yes El No <br /> 4 gI;pDR'ALL: Yes ❑ No <br /> S. ASPSALT CONCRETE DIFF: Yes El No <br /> 6. BARRIERS along R.rght-c£Way Other ❑ Wier DeP <br /> Yes ❑ No ifyes: V Style ❑ 2 Poivt ❑ <br /> 7. DITCH «««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»PEII REQUIREMENTSAC3RtCiJi-TE7RE ❑ INDUSTRIAL ❑ <br /> SFR ❑ coh,0tERCIAL <br /> 1.DRIVEWAY: PAVED <br /> Min.Depth 3/4"A.B. <br /> PAVED with �_."�O'Dem A.C.over __ <br /> Notes <br /> Ler1gN►of Pipe Regairad: Ft and Diameter of Pie _....-------Inch - <br /> i PIPLfx Yes ❑ No <br /> TO be connected to any ad.1 driveway <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> ��Pte} Total NMI) of Storm Draft inlets - <br /> - Tout Leh' _.__._----•----- <br /> Notes <br /> 3. HEADWALL yes ® NO "Mia Depth 3/4"AB. <br /> PAVED with "lvfm.Depth A.C.over �.•_ <br /> 4. PAVED FRONTAGE: Feet in width <br /> Measuring - Feet in length and <br /> FEES <br /> Driveway Encroachment <br /> Permit base fee...........................$85-w <br /> :. .$100.00+o.46/ft <br /> FieldIn�C:tion ,� ❑Pavedfrcu -_....._._------..._-. <br /> .$95.00 X a $140.00+0.98/ft <br /> ['Driveway w/or w/o piPe....................._.._...._ $155.00 ❑Curb.Gutter,Sidewalk..................... <br /> .......... . <br /> ❑Driveway w/box Culvert......................... Revised 8/20 <br /> 00 <br /> Courrter\Computer,c:\Aaxss\Applicationfor Pennits\Driveway <br /> and Paved Frontage Page 2 of 2 <br />