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THE APPLICANT HEREBY CERTEIES: <br /> 1. That he/she has read all the provisions of this application,and that the deseriptim included in this application are cornet to the best of his/her <br /> knowhadge;and <br /> 2. That bilabe is the owner of the respective propertyor propertyisqualified to represent the owner,and <br /> 3. That he/she will assume full responsibility for all liability for personal i*"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 loan or any department official or <br /> employee thereof;her shad <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 eve of the applicant m the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County En ant Permit;and <br /> b. That if permission is grantedas re rees Ito do the work deambod in accordance with all terms,conditions and restriction of this and any <br /> attached shee vier <br /> h of a Date <br /> FIELD INSPECTOR COAEM$NTS <br /> »»»»»»»»»»»»»»»»»»»>>EXISTING CONDMONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nome ❑ Dirt ❑ Gravel ❑ AWvgate BaseJ� Pav <br /> od(Poar) ❑ Paved(God) ❑ <br /> 2.. SLOPING: Away from Pavement Towards Pavemaot ❑ Flat ❑ <br /> 3. PIPES: Nome it Existing-Type <br /> Other pipes in Yes ❑ No Approaches ❑ Crow Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' k <br /> S. ASPHALT CONCRETE DIIfE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No If Yea: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR t�' COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over _ A!�_"Min.Depth 3/4"A.B. <br /> Notes <br /> E- <br /> L PIPES: Length of Pipe Regained; It and Diameter&Pipe Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No ] _ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Tom (with proposed) Total Number or Storm Drama Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over ^Min Depth 3/4"A.B. <br /> M8 Fent in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee........................... 85.00 <br /> ield Inspection <br /> Driveway w/or w/o pipe:.............................................. $95. ❑Paved $ <br /> fra nt a age................_.............. 100.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CountealComputer,c:kAccess\Applieation for PermitslDrive:way and Paved Frontage Page 2 of 2 Revised 8/2000 <br />