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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has mead all the provisions of this application,and that the description included in this application are correct to the bast of his/her <br /> 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 responvibmlity for all liability for persoaad injury or damage to property which may wise out of the work described above, <br /> or which may arise out ofhis&er 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 3'osgi us or my department,official or employee thereof;he shall <br /> defend,mdenmdy and hold them and each of them harmless for sods claim;and <br /> 5. That work shall be performed by the aMhcamtt and/or any r atite of the applicant m the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all temis,conditions and restriction of this and any <br /> �atrtached ,-t, d�i �xa11D provisions. <br /> Srgature ofApplicast-Tide, Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nene Dirt ` <br /> ❑ Gravel ❑ Aggcagate Base ❑ Paved(pcmor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awa from PavawAwt ❑ Towards Pavement Flat ❑ <br /> 3. PIPES: Now Existing-Type <br /> Other Piles in Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attadmseot to neighbor's Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S ASMALT CONCRETE Dir Yes ❑ No l J <br /> 6. BARRIERS alengRight-cf•Way ,\ <br /> 7. DITCH Yes ❑ No IfYos: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»PERMIT REQUIR E)MM«««««««<<<<<<««««««« <br /> 1_DRIVEWAY: SFR ❑ COMMERCIAL AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Z "W.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPE& Length of Pipe Required: Ft.,and Diameter of Pip, Inds <br /> To be connected to any adjacent driveway pipe Yes ❑ No �- <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total (with proposed) Total Number of Storm Dnin Inida <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "141m.Depth A.C.over "&fim Depth 3/4"A.B. <br /> Measuring Feet in Length and Feet in width <br /> FEES <br /> Driveway Enaoacbmem Permit base fee............................$85.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe.......... ........_...._._. .._...__595.00 ElPaved <br /> &z+stage.-_..........-__......._.S100.00+0.46/R <br /> Driveway w/box Culvert............................................$155.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> Counter\Computer,c:\AccessWpplication for PermitslDriveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br />