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APPLICANT HEREBY"]it FZE in this application are owed to the best of his/her' <br /> Y4ztiS ',;I. Thad he/she has read all the provssso06 ofthisappficgdon <br /> ,and that the descsiphost rocluded <br /> knowlwdge;and <br /> ,oris quaMedto represent the owner;and <br /> 2. That he/she is the owner of the respective ProP=3' arise out of the work described above, <br /> 3. That he/she will assume full responsila�ty for all USIAly for pmsoml injury or damage to ProPmiy which <br /> ms y <br /> or whichmay arise out ofhis/h�faiinre to do the work <br /> or <br /> of San Joaqion orany a�isl ampthe he shall <br /> 4. That in the event any claim of such IiAWY is made sga► Cou�y <br /> defend,indemnify and hold them and each of them harmless for such e1=6 and -0f a/a at the above indicated site <br /> b lieant and/or any represe+otative ofthe applicant in the Coupty y <br /> 5. That work shall be performed y app and <br /> with a valid San Joaquin County Pew <br /> to do the walk described in at:cacdance with 9H terms, �°tl <br /> ° s and restriction.ofthis and any <br /> 6. That if pemiissian is Wanted as requea#ed,he agrees <br /> attached ded as general or Vemll ons' 7 zoo/. <br /> Date <br /> Sipstamof <br /> FIELD INSPECTOR COMMENTS <br /> »»'»»»»»»»»»»»»»»»»»>EXI TU4GCONDIT1ONS«<<<<< ««««««««««««« <br /> L DRIVEWAY: <br /> None �' Dirt ❑ Gravel ❑ Aute Base ❑ Paved(P") ❑ Paved(Good) ❑ <br /> Awa from Pavement ❑ Towards Pavm>aot El Flat <br /> 2. SLOPING: y <br /> 3. PIPES- None Existing'Type <br /> Drain Size <br /> Other pipes m nagbborhooa: y <br /> Yes ❑ No ® App ❑ Cross ❑ C� <br /> Attacimeut to ndghboes Pipe: Yes ❑ No <br /> L BEADWALL: Yea ❑ No <br /> S. A,SpffALT CONCRETE DM: Yes (� No ❑ <br /> ti.BARRIERS akmg Reght-ot=Way <br /> 7. DITCH <br /> Yes ❑ No Ifyes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT <br /> 1.DRIVEWAY: SFR <br /> CO1V WRCIAL ❑ AGRICULTURE ElINDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES% Length of Pipe Rzgairod: Ft and Diameter of'Pipe � Inch <br /> To be comecte any adjacent driveway}ripe Yea ❑ No <br /> #o ' <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: (with proposed) Total Number of Storni Drabs Inlets <br /> Notes <br /> 3. HEADWALL yes no NO <br /> 4. PAVED FRONTAGE: PAVED with "Min Depth A.C.over "Min Depth 3/4"A B. <br /> Measuring Peet in length and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee.................:... .....$85.0 <br /> Field Inspection $100.00+0.46/ft <br /> ❑ Driveway wl or w/o pip,........................._.............._. ..$91.00 ❑Paved framtaga.••-......._._........:........ <br /> Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.....................$100.00+0.98/ft <br /> El <br /> Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access�G--tion for Permits\Driveway and Paved Froo age <br />