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APPLICANT HERE$Y CERTIFIES= <br /> #he/she has read all the provisions ofthis application,and that The demiptionincluded inthis application are correct to the beat of his/her <br /> '4a2 kmowlwdge;and <br /> nt the owned and <br /> That le/sheisthe ovvne�'afthareapedive property,or is gmMedto mFWe <br /> h �, P , to propaiy,&,hmay arise out ofthe work described above, <br /> 3. That he/she will assume full respons�Y <br /> or which may arise out of hislher faRure to do the warkprovided Herein;and or my dqmtn�offCislor y�tht shall <br /> 4. That in the event any claim of such liabiffty made against The County of Saar h>agion <br /> fid,indemnify and hold them and m&ofthem harmless fes such claim;and -of-Wer at the above indicated site <br /> S. That work shall be performed by this appf'carit and/or any repses a of the applicant in The Coutty Rigbt Y <br /> with avalid San Joaquin County EacroadmudPecmk;and <br /> -t4 he agrees to do the work described in accordance wadi all tams,conditions and restriction of ibis and any <br /> 6. That if permission is grassed as requ <br /> aftacled dot as or special M provisiosss <br /> Date Y <br /> Si ARAc ast-Title <br /> FIELD INSPECTOR COMMENTS <br /> L DRIVhL+WAY: Bane <br /> Dirt I] Drava E] Aggegata Base ❑ Paved(poor) ❑ P8° ❑ <br /> 2. SLOPING: <br /> Away from Pavement ❑ <br /> Towards Pavemart Flat El <br /> 3. PIPES' Now Egg-Type <br /> tJthm'pipes in neighborhood: <br /> Yes ® No ❑ Approaches ❑ Cross Drain ❑ Sia <br /> Attad mot to nd&or's pipe: Yes ❑ No ❑ <br /> 4.HEADWALL: Yes 9 No ❑ <br /> S. ASPHALT CONCRETE DOM: Yes ❑ No <br /> 6. BARRIERS along 1ti*-Q£Way <br /> 7. D]fTCH Yes No ❑ IfYes: V Style f 2.Point ❑ Odw El Width <br /> h <br /> NTS«««««««««««««««««««« <br /> »»»»»»»>>>>>>»»»»»»»PERMiT REQUIItEME <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRk1jLTURE ❑ INDTJSTRL L ❑ <br /> PAVED with "Min.Depth A.C.over "Mi%L Depth 3/4"A.B. <br /> Notes <br /> 2 PIPM Length of Pipe Regoirod: Ft.and Diameter of Pitse Inch <br /> To be connected to any a4aca t driveway pipe Yea ❑ No <br /> DRARjA(E INLET REQu RED,_.- - Yes. ❑ No <br /> Total L eogth: (with pmposed) Total N>mnber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Ivim.Depth AC.over "Min.Depth 3/4"A.B. <br /> Measuring Fad in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee....................... ...$85.00 <br /> Held Inspection <br /> $9iPaved 00+0.46/ft <br /> El Driveway w/or w/o pipe.------------_---------.._---_ _._. .. . ❑ e_..._._._........_.:.._.._S190. <br /> .$155.00 Curt,Dotter,Sidewalk.....................$190.00+0.98/ft <br /> ❑Driveway w/box culvem........................... <br /> Couirta\Computer,c 1AcxessWpplicati0n for PetmitslDriveway and Paved Frontage Page 2 of 2 <br /> Revised 8/2000 <br /> 1 , <br />