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APPLICANr HEREBY CERT S: <br /> That helshe hes read all the provisions of this 90=60136 and thatthe,daecriptian included in this application are correct to the best ofhis/hu <br /> =' knowlwdge;and <br /> That he/she is the owner ofthe respective property,or is quaMedto represent the avvmr,and <br /> 3. Tbat he/she will,assume full responsibility for all liabrirmy for persmrah injury or damage to property whichmay arise out of the work described above, <br /> or which may ase riout of his/her failure to do the wo&provided herein;and <br /> 4. That is the event any claim of such tiabiKty is made against the County of Saar Joaqim or any department official or employee dwec&he shall <br /> defend,indemnify and hold them and each of them harmless far such claire;and <br /> 5. That work shall be performed by this applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County FAwroadmumt Permit;and <br /> 6. That if pamrissi ol is qanted,as requested,he agrees to do the work described in accordance with all temrs,conditions and restriction ofthis and any <br /> _4 t III provisions. <br /> A W)t?lml �_. <br /> SigaaTm+e Applic�-Tide � <br /> FIELD INSPECTOR COAVMNTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTINO CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt J0 Gravel ❑ AMegate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ® T.,,&Paves ❑ Flat ❑ <br /> 3. PIPES: Now EAsting-Type <br /> Other pipes in.nei&borhood: Yes ❑ No ,R1 Approaches ❑ Cross Dmm ❑ Size <br /> Attaxhment to neighbor's pipe: Yea ElNo <br /> 4 HEADWALL: Yes ❑ No <br /> S. ASMALT CONCRETE DIICE: Yes ❑ No <br /> 6. BARRIERS along Rigit-cff way. <br /> 7. DITCH Yee El NO IfYes: V Style E] 2.Poiot E] Other ❑ Widdr Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGOCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "tuba Depth A.C.over "Mia.Depth 3/4"A.B. . <br /> Notes <br /> t. PIPES: Length of Pipe Requited Ft.and Dimader of Pipe _ Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INL,ETREQUHtED' ;:-_ _Yee ❑ No <br /> Total Length: (widr proposed) Total,Number of Storm Drain Inlets <br /> Nadas <br /> 3. HEADWALL Yes ® No �] <br /> 4. PAVED FRONTAGE: PAVED with "Ivfm.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Measuring Feet in fength and Feet in width <br /> FEES <br /> Driveway Facroachwent Permit base fee......................... 585.0 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe....................... _ .$9i.OD ❑Paved _ +0.46M <br /> ❑Drivewayw/box Culvert......................_..................._....$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:lAccesslApplication for PermitslDriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> i . <br />