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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this applicatim and that the description inchtded Mathis application are correct to the best of his/her <br /> lmowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to tit 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 ofthe 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 Jbacpun or any department,official or employee thereof he shall <br /> defend,indemnify and holdthem and each ofthem harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any rive of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Enc roadiment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the wodr.described in acoordance with alt temts,conditions and restriction of this and any <br /> sh90900or vial <br /> dxz "i I - I <br /> jk, <br /> Sigoatrue of Applicaut-Title Date <br /> FIELD INSPECTOR COMIENTS <br /> EXiSTEgG CONDITIONS«««««««««««««««««««« <br /> Az <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base P.-,.%oar) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Amy from Pa ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Eursting <br /> Other pipes in neighborhood: Yes 9 No ❑ Approaches ❑ Cross Drain ❑ Size <br /> Attadmient to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S. ASPS ALT CONCRETE DUM: Yes ❑ No <br /> & BARRIERS along Right-of-Way <br /> 7. DITCH Yes ;k No ❑ IfYas: V Style 2 Point ❑ Otber ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REWUM4ENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR )d 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 Indy <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 . <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.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 'on <br /> ewayw/orw/o pipe.........._.....................................$95.00 ❑Paved frontage........... . .................$100.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,SidewalL......................$100.00+0.98/ft <br /> CounterlComputer,c:Wccess\Apphcah-for PermitslDriveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />