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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best <br /> his/her knowledge;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 persona;injury or damage to property which may arise out of the work <br /> described above,or which may arise out of his/her failure to do the work provided herein;and <br /> 4. the <br /> shalltdefend,indemnify liability <br /> ndlh Id them anis made d eachainst the of them County mess forof San asuch claim;anuin or any da�ment,official or employee <br /> 5. That <br /> work <br /> si hall bh performed valid by <br /> the applicant <br /> County Encroachmentd/ any <br /> r sentativ d f the application in the County Right-of-Way at the above <br /> cated <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and any attached sheet,included as general or special III provisions. <br /> X - Y Date <br /> 5Z�ii�dnatitle <br /> »»»»»»»»»>>>>> >/»»»»»»»FIELDISE CON COI MENTS««««««««««««««««««««« <br /> ING <br /> NS <br /> 1. DRIVEWAY: None T(Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement//.�Flat <br /> 11 Z ❑ <br /> 3. PIPES: None ©� Existing—Type Cu'7<t`� �'`I �lvu''�rG e. <br /> Other pipes in neighborhood: Yes N Approaches oss Drain Size <br /> 4. HEADWALL: Yes EJNo Eli <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ NoEl 6604 E <br /> 6. BARRIERS: along Right-of-Way <br /> 1;116 14 Z <br /> 7. DITCH: Yes ❑ No [t]/If Yes: V Style ❑ <br /> 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREM ENT S««««««««««««««««««««< <br /> 1. DRIVEWAY: SFR E]/ Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with �` "Min Depth A.C.over "Min Depth'/<"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> Ft.and Diameter of Pipe �j`� inch(e; <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> ET <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> 4 <br /> - <br /> Notes: <br /> L <br /> 3. HEADWALL: Yes ❑ No <br /> "Min Depth A.C.over "Min Depth'/<"A.B. <br /> 4. PAVED FRONTAGE: Paved with length and Feet in width Feet in len <br /> Measuring g <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Ins ection110.00 H <br /> Paved Frontage <br /> Driveway w/box Culvert $116.00+0.53/ft. <br /> Driveway w/or w/o pipe $179.00 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> $ <br /> 11SJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIV WAY.DOC (10/09) <br /> Page 2 0(2 <br />