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jJU APPLICANT I3EMBY CERTHIES: wk)&d in this application are correct to the best of his/her ` <br /> Ttad he/she has read alt the provisions ofthis appn,sod that <br /> the desctipRioni <br /> ,�.,. . <br /> is knowlwdge;and <br /> respective or edtorgtresetttthaowt►e>;and <br /> Thai helshe is the owner of the reapacii prop 3� c damage to 1 'whichmsy arise out ofthe work described above, <br /> 3. That he/she will assume full responnV Y for ill 1iabTdy for personal injury <br /> or which may arise out of his&w failure to do the warlkpmvided he('ein;and official employee or the he strati <br /> 4. That in the <br /> event any claim of such liability ismade agawdlheCOUdY or any deparhment, <br /> defend,indamn>fy and hold them and each ofthem hmmleas for suds claim;and .of wa at the above indicated site <br /> 5. That work shall be Pafomwd by the applicant and/or <br /> say rapt of the applicant in tate County Right Y <br /> with a valid San Joaquin County Eaawdmaeut Pew and oon&twms and rest fiction of this and any <br /> 6. That if Permission is granted as requested,he agrees to do the work described in accordance 6. <br /> all tames, <br /> included or spedw III protons. / <br /> JI <br /> Date <br /> Sig att—ofApplicant-Tid- <br /> FIELD INSPECTOR COMNZNTS <br /> »»»»»»»»»»»»»»»»»»»>>EW�O CONDMONS«««««««««<<<<<<««««« <br /> None �. <br /> Dirt ❑ Gravel ❑ Aggregate Base ElPave&poor) ElPavad(Good) ❑ <br /> L DR�EWAY: <br /> 2. SLOPING. <br /> ent ElTowards Pavement ❑ Flat <br /> Away from Pavem <br /> 3. PIPES: None Egg-Type <br /> Other pipes in neighborhood: <br /> Yes ❑ No Approack" ❑ Crow train ❑ Size C� <br /> Attachmeatto neighbor's pipe: Yes ❑ No <br /> 4.]UL4DWALL: Yes ❑ No <br /> S.ASPHALT CONCRETE DUO. Yea ❑ No <br /> ti. BARRIERS at-*Right-£Way <br /> Depth <br /> 7. DITCH <br /> Yes ❑ No Ify.: V Style ❑ Z Point ❑ Other ❑ Width <br /> »»»»»»»»»»»»»»»»»»»»PERMiT REQUMEMENTS <br /> «««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ Ac33RtCE71 TtJRE ❑ INDUSTRL4,L ❑ <br /> PAVED with "W=Depth AC.over "Min.Depth 3/4"AB. <br /> Notes <br /> 2. PIPM I-Igh of Pipe Fk and Diameker of Pipe ► <br /> Tobe connected to any adjaant&ivewaY l Yes El No <br /> - - ❑ No <br /> D1tAIFdA�3E-TNE:E'TREQZJIRED . ' Yea <br /> Total Length: (with proposed) Tata1 Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Ya ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Mi Depth AC.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee........................ ..585.0 <br /> Field Inspection <br /> $100.00+0.46/ft <br /> ❑ Driveway w/or w/o r _.e5.00) <br /> ❑Paved fi�artage..--.._....-...--....-.^ <br /> ❑Driveway w/box Calvert................................................ ❑Curb,Gutter,Sidewalk......................$100.00+0.98M <br /> Counter\Computer,c-\Aecess\Application for PermitsM)riveway and Paved Frontage Page 2 cf 2 Revised 8/2000 <br /> 'I <br />