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APPLICANT]HEREBY CERTHUS: <br /> 11M he/she has read all the provisions ofthis appy,and that the descaiptim inhaled in this application are.correct to the best ofhis/her <br /> knowlwdgq and <br /> That be/she is the,owner of the respective property,or is qualified to represmR the owner;and <br /> 3 Tba3 he/she will assume fullreaponsil ity for all liabsTdy for persomd i Vary ordanmage to i Y+* � Y e o of the work described above, <br /> or wbich may arise out of Maier failure to do the wads provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of Sam Joaqiun or any department,olficisl m employee thereof;he shall <br /> defend,indemnify and holdthem and earn ofthem harmless for such clean;and <br /> 5. That work shall be performed by the&Mhcmt and/or.any representative of the applicant in the County Right-of-way at the above indicated site <br /> with a valid San Joaquin Courtly Eacroad mmt.Pew f;and <br /> 6. That if permission is granted as regi agees to do the work described in accordance with all terms,oouditions and restriction of this and any <br /> auachea sheet included as 1 ar s ro <br /> A//ate V6 <br /> Si Tine Date <br /> FIELD INSPECTOR COh 4IENTS <br /> »»»»»»»»»»»»»»»»»»»»E.XiSTE-16 CONDMONS«««««««««««««««««««« <br /> L DRIVEWAY: Nome Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(pom) ❑ PaveAGood) ❑ <br /> Z SLOPING. Away tram Pavement ❑ T..,&Pavement ❑ Flat <br /> 3. PII'ES: None Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Dram ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE D]XE: Yes ❑ Na <br /> 6. BARRIERS along Rigbt-ct way <br /> 7. DITCH Yes ❑ No .�d IfYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SIR ❑ COMMERCIAL ❑ AGRiCATURE ❑ MDUSTRIAL ❑ <br /> PAVED with "IAm.Depth A.C.over "Min,Depth 3/4"AB. <br /> Notes <br /> L PIPM Length of Pipe Required: Pt.and Diameter of Pipe Inch <br /> To be comeded to any adjacent driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yin ❑ No J� <br /> Total Length: (with proposed) Total Nwaber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with / "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet is knS&and Feet in width <br /> FEES <br /> Driveway Eameachment Permit base fee...........................$85.0 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe....................................__ ...$95.0 ❑Paved finntage._.__._._. _ ..$100.00+0.46/ft <br /> ❑Driveway w/box C ulverL......................_.........................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:V cc—\AMlication for Permits\Driveway and Paved Frontage Pages 2 of 2 Revised 8/2000 <br /> • i <br /> i <br />