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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of his:lier <br /> knowlwdge;and <br /> 2. That he/she is the oNvuer of the respective property.or is qualified to represent the owner,and <br /> 3. That he%she will assure frill responsibility for all liability for personal injury or damage to property which may arise out ofthe work described aboN:. <br /> or which may arise out of his/her failure to do the work provided herein-,and <br /> 4. That in the event any claim of such liability is made against the County of San Joagiun or any department,official or employee thereof.he shall <br /> defend,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 a valid San Joa County Encroacl �rmit;and <br /> 6. That if pernissior s "anted as requ ed,he a es to do the work described in accordance with all terms,conditions and restriction ofthis and any <br /> attached shee uded as gener or sp cal Iii pr cons. <br /> Signature of App ,ant-Title Date <br /> FIELD INSPECTOR COMNIENTS <br /> ENISTING CONDITIONS «_ ,< " _ _, <br /> 1. DRIVEWAY: None Dirt ❑ Gravel [r Aggregate Base Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement Flat <br /> 3. PIPES: None -- Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Anaelunent to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes Noa <br /> 5. ASPHALT CONCRETE DIKE: Yes [] No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes Fk No ❑ If Yes: V Style FV�2 Point ❑ Other 1 Width Depth <br /> PERMIT REQUIREMENTS <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ] INDUSTRIAL, =J <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑' No !� <br /> DRAINAGE INLET REQUIRED Yes _ No LV <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Note - - <br /> 3. HE4DyVALI, Yes ❑ No [�]' <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3i4"A.B. <br /> Measuring Feet in length and Feet in width <br /> —� FEES <br /> Drivewav Encroachment Permit base fee..__......... .....585.00 <br /> Field Inspection <br /> Drn ewav w or w o pipe ___ .. _...--_... - Paved frontage ...............S 100.00 11.46 h <br /> Driveway�a,bo Culvert......_........................................S155.00 __ Curb.Gutter.Sidewalk.......................S100.00-0.98 6 <br /> Counter.Computer.c:,Access`,Applieation for Pennits`.Driveway and Paved Frontage Page 2 of 2 Revised 8:2000 <br />