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jH1 APPLICANT HEREBY CERTIFIES: inthis ou are correct to the best of his/her <br /> That he/she hes read all the provisions of this apples,and ilet the description iochded <br /> k,, lwdge;and <br /> oris edto rquesed the owner;and <br /> 2, Thowner <br /> at helshe is the of the respediveproP�i}', 4+t�fi <br /> 3. That he/she will assume full re:pamsibn'1rt'Y <br /> for all 1 +t5'for pasonai=M or <br /> damage to properly vdnch may arise out of the work described above, <br /> or whichmay arise out of his&W failure to do the work paovided herein;and od6cisl Cher e�he shall <br /> 4. That it the evert any claim of such liabiYty is made against the County of San Our any <br /> fid,;nary and hold them and each ofthem harmless for such chum;and <br /> the licant and/or any of the applicant in the Conrrty Right-of--Way at the above indicated site <br /> 5. That work shall be performed by apP <br /> vvith avalid San Joaquin Corny Eacroachmat Permit;and <br /> 6. That if p <br /> anis as r est�d,he agrees to do the work described in acomdanoe with all terns,conditions and restriction of this and any <br /> *.bed eet,included as visi°ns D(� <br /> Dare <br /> S' Appy-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»> EXISIM40 CODONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dirt ❑ Gravel ElAggregate ❑ paved(pow) ❑ Pa ) ❑ <br /> 2. SLOPING: Away&aa Pa rmd ❑ Towards Pavement Flat El <br /> 3.PIPES: Now Existigg-Type <br /> ti <br /> Other pipes in neighborhood: <br /> Yes ❑ No Approah.. ❑ Cross Drain ❑ Sm C� <br /> Attachment to neighbor's pipe; Yep ❑ No <br /> 4.IMADWAId.: Yea ❑ No <br /> S.ASI+HALT CONCRETE DIME: Yes ❑ Na <br /> 6. BARRIERS along RigLt-af-way <br /> Depth <br /> 7. DITCH Yes ❑ No ❑ IfYes: V ❑ 2 Point ❑ Other ❑ Width <br /> QTS«««««««««««««««««««« <br /> >>>>> »»»»»»»»»»»»»»PERMIT REQUIRE <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL AGRJCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mia Depth A.C.over "Mia Depth 314"A.B. <br /> Notes <br /> L PIPES: of Pipe Rb*ti"d: Ft.and Diauneter of Pipe Inch -- <br /> To be cameded to any 2440011tdriwmY Pipe Yea El No <br /> DRAINAGE INLET REQUWD Yes ❑ No <br /> Total Lengdr (with proposed) Total Number of Storm Dry Ldels <br /> Notes <br /> 3. HEADWALL Yes Mn No <br /> 4 PAVED FRONTAGE: PAVED with "Mho Depth A.C.over "Mia Depth 3/4"A.B. <br /> Measuring Fed in.Iength and Feet in width <br /> FEES <br /> Driveway Fnavad meat Permit base fee.......................... s.00 <br /> Field Inspection <br /> 595.40 aved f�age.-.-------......--..".__..$100.00+0.46/ft <br /> El w/or w/o pipe.......................:.._............._.-.. ..$140.00+0.98/R <br /> ElDriveway w/box Culvert.................................................$155.00 kcurb,Clutter,Sidevvalk..................... <br /> Counter\Computer,c:\Access\Apphcabon for Permita\DnVeway and Paved Frorrtage <br /> 2 oft . Revised 8/2000 <br />