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THE APPLICANT HEREBY CERTIFIES: <br /> L 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/her <br /> knowiwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to property which may arise out of the work described above, <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 ofthe applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin oachment Pemmit;and <br /> 6. That if permission is gran d as �sted,he agrees todo the work described iuaccordance with all terms,conditions and restriction of this and any <br /> attache et,included as oeciai III provisions. <br /> 4/ <br /> Signature of Applicant-Title ate <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING COND3TIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved( ❑ Pavod(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 /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No ❑ <br /> 5. ASPHALT CONCRETE DE": Yes ❑ No ❑ <br /> 6. BARRIERS along Ri&-of-Way <br /> 7. DITCH Yes ❑ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <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 ❑ <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No 0 <br /> 4. PAVED FRONTAGE: PAVED with "Min_Depth A.C.over "Mim 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 /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.................................................$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/boxCulver.................................................$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.9811 <br /> CounterlComputer,c:\Access\Application for PecmitsTriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />