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"''''``'`SIE APPLICANT)EIERE$Y CG"ERT�S: <br /> A w in this application an correct to the best of his/her �• <br /> ' <br /> That he/she has read all the provisions of this application,and that the descxipticn <br /> s„ ,J <br /> knowlwdgv,,and <br /> That he/she is the Owner of the terve ptopat}S <br /> or is qualified to rgrssentte own9 and <br /> 3, That he/she will assume full r�for'U <br /> ,for ,or damage prply,,k&mry arise out Ofthe work described above, <br /> or which may arise out of hisll:er failure to do the waaic provided basin;and oras of6cisl m eayee thereof, shall <br /> 4. That inthe event an}+claim of such tiabiYdy is made against the County of San y <br /> defect,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with avalid San Joaquin County EncrawhmftR Permit;and <br /> pennissim is 1�ed as�estod,he arm to do the¢ work bed is accedence with all temps,ooaditions and restriction of this and any <br /> 6. That <br /> atkacl�tl e , ded or aP III _rl,�—1-2 O <br /> of Appficani-Title Date <br /> ` FIELD IIVSPECPOR COmmENTS <br /> «««« <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>�ESS{-,COMMONSMONS«««««««««««««««« <br /> Gmvel Aute Base ❑ Paved(poo) ElPav*Good) ❑ <br /> L DRtVMAY: None ❑ Dirt ❑ Flat <br /> 2. "PING. Awayfinm Pavement ® Towardv Pavement E) <br /> 3. PIPES: Now EAWng-Type <br /> h Size <br /> Odw Pipes is� : Yes ❑ No ® Approaches Cross Drain ❑ <br /> Attac:bm"to neighbor's pipe: Yes ❑ No <br /> 4.iff, DWAIL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIKE. Yea ❑ No <br /> 6. BARRIERS aloe$Right-of-Way <br /> 7. D1TCH Yes E] No Ifyes: V Style ❑ 2 Point El Other ElWidtln Depth <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AORk-ULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Wa Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> Pt and Diameter a£Pipe bah <br /> 2. YIPS.& Length of Pipe Regntred: -- <br /> To be oomeoted to say ad}acxat driveway Pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yee ❑ No <br /> Total : (with proposed) Total Number of Storm Drain Wets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...................... ....$85.00 <br /> Feld Inspection <br /> ❑Driveway w/or w/o pipe.......................... _._ <br /> .$93.00 ❑Pavadfimtage.-._..._._...........:----$IOO.tx1+0.46/ft <br /> ❑Driveway w/box Culvert................................. .$15500 <br /> El curb,t3utter,Sidawallc......................$100.00+0.98/ft <br /> Counta\Compute,c:\Access\Appiication for Parnits\Driveway and Paved Frontage Page <br /> 2 of 2 Revised,8/2000 <br /> I\ <br />