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THE APPLICANT HEREBY CERTHIES: <br /> 1. That he/she has read all the provisions of this application,and that the deserip m included in this application are cohred to the best of hisJher <br /> lahowlwdge;and <br /> 2. That he/she is the owner of dw respective property,or is qualifiedto represent the owner,and <br /> 3. That he/she wilt assume fall responsibility for all liabirdy 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 worts provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San Joagiun or any department,official or employee theaeot he shall <br /> defend,indemnify and holdthen and each of them harmless for such claim;and <br /> 5. That work shall be the applicant and/or any eve of the applicant in the Courtly Right-of-Way at the above indicated site <br /> with a valid San J Encroachment Peru ik and <br /> 6. That if permissimu is s requested,he agrees to do the wok described in accordance with all teens,conditions and restriction of this and any <br /> attached sheet include euerxl ar special III provisiorhs <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COM11dENTS <br /> »»»»»»»»»»»»»»»»»>F»»EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nome EJDirt Gravel ❑ Aggregate Base ❑ Paved(poor) ElPaved(Good) ❑ <br /> * SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: Now ❑ EAsting-Type IZCQQQATE;�' 5+65( <br /> Other pipes in neighborhood: Yes No ❑ Approaches ❑ Cross Drain ❑ Sire <br /> Attachment to neighbor's pipe: Yes No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIICIS: Yes ❑ No <br /> 6. BARRIERS alongRigk-of <br /> 7. DITCH Yes No ❑ IfYes: V Style &2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENT'S«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR 1K COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with _2"Min.Depth A.C.over �_"Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Required: Pt and Diameter of Pipe h <br /> { inc <br /> To be oomected to any adjacent driveway pipe Yes 1�1 No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No it <br /> Total Length: (with proposed) Total Number of Storm Doak 1B1ets <br /> Notes <br /> 3. EWADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth 3/4-AB. <br /> Measuring Fed in kagth and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Id Inspection <br /> 16k&veway w/or w/o pipe................................................$95.00 ❑Paved fiaarage._....._.... _._...........$100.00+0.46/ft <br /> ElDriveway w/box Culvert................................................$155.00 ❑Curfi,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\AccesslApphcahon for Permits0riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> I <br />