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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That helshe has read all the provisions of this application,and that the des <br /> knovvlwdg�and imclrxied in this mon are owed to the best of his/her <br /> 2. That he/she is the owner of the respective ptnperiy,or is qualified to represent the ownev,and <br /> 3. That helshe will assume full responsihility for all liability for personal injury or danzage 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 JD&gim or any department,official of employee thereof he shall <br /> defend,indemnify and hoidti m and each of them harmless for such clauq and <br /> 5. That world shall be perfomned by the applicant and/or any representative of the applicant in the County Right-4-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment ppm and <br /> 6. That if permission is granted as requested,he agree to do the work described in aocordance with all teens,oonditions and restridion of this and any <br /> attar.. . included as g III provisions. <br /> Signature ofApplica t_Tide <br /> Date <br /> FIELD INSPECTOR CODMIENTS <br /> EXISTMG CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dnt ❑ Gravel ❑ Amngate Base [] Paved(pow) ❑ Paved(Good) <br /> 2. SLOPING: Away from Pavement �] Towards Pavement ❑ Flat <br /> 3. PIPES•. Nome IN, gig_Type <br /> Other pipB8 n neighborhood; Yes ElNo Approaches El Cross Drain <br /> EJ S� 0 <br /> Attachment toaeiglibot's ; .Yes ElNo <br /> 4. HEADWALL: Yes ❑ No IL�k <br /> S. ASPIIALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-o&-Way <br /> 1. DITCH Yes ❑ No X Ifyes: v Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»">""""'""""">>>»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "wm.Depth A.C.over <br /> _ Atm.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft and Diameter of pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑l No, 191 <br /> DRAINAGE INLET REQUIRED Yes ❑ No IJ <br /> Total Length: (with prop) Total Nu aber or storm Dry fnld#s <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Lfin.Depth 3/4"A.B. <br /> Mpg Feet in length and Feet in width <br /> Driveway Fncroac>m e t Permit base fee............................$85.00 FEES <br /> ,Fiie tion <br /> l.t�Driveway w/or w/o pip e.............._....._......_.._..._.....-:05.00 $100.00+0.46/ft <br /> ❑Paved SnonCage,.._............__..._.... <br /> ❑Driveway w/bo.Culvert.......................... .$155.00 <br /> ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,cAAccess\Application for Pamits\Driveway and Paved Frontageo <br /> �2f 2 Revised 8/2000 <br /> A <br />