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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 of <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 event <br /> shall defeclaim of such nd,indemnify andihold them anis made d eachthe <br /> of.them h mess foof San rsquin uch ecla myandartment,official or employee <br /> 5. That wshall b a performed <br /> San Jothe applicant omy Encroachment o any e pt sentative f the application in the County Right of-Way at the above <br /> indicated <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 aitac ed s�e ,included as general or special III provisions. �r <br /> Signature of Applicant Title ate <br /> »»»»»»»»»»»»»»»»»»»»»>FIE DI <br /> EXISTING ION OMM NTS«««««««««««««««««««««< <br /> re [I Paved(poor) ❑ Paved(good) <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Agg 9 ate Base <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat, <br /> 3. PIPES: NoneiZ Existing—Typeroaches Cross Drain Size <br /> Other pipes in neighborhood: Yes ria App <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE:.Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No X If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial F1Agriculture ❑ Industrial F] <br /> Paved with y "Min Depth A.C.over "Min Depth 1/4"A..B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> g Total Number of Storm Drain Inlets: <br /> Total Length: (with proposed) <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> "Min Depth A.C.over "Min Depth 3/V A.B. <br /> 4. PAVED FRONTAGE: Paved with <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»>>>»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $135.00 <br /> Field Ins ection121.00 HCurb, <br /> Paved Frontage $116.00_+0.53/ft. <br /> Driveway w/or w10 pipe $121.00 Gutter,Sidewalk $121.00+1.16Ift. <br /> Driveway w/box Culvert $ <br /> ...,.r.ernu rrnlnrCCIN CDirnl\DI 10-C1/IDIv1In CT[pDC\LTIrDhAruM[AT OCDAAIT nOn/RAIGV nnr maH 91 <br />