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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of his/her <br /> knowlvdge;and <br /> 2. Tbat helshe is the owner of the respective property,,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for personal uyuryor 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 Joagiun or any department,official or employee thereof;he shall <br /> defend,indenmify and holdthem and each ofthem harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant m the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin Couaiy FAcroacl Permit;and <br /> 6. That if pe is granted as requested,.he agrees to do the wads descaibed in accordance with of terms,conditions and restriction ofthis and any <br /> attached shee uded as general or special III provisions. <br /> Sigoarime ofAn licant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nene ❑ Dirt ❑ Gravel i Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> L SLOPING: Away 1row Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Nene W Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attadnnert to neighbor's Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No" ,f <br /> S.ASPHALT CONCRETE DUM: Yes ❑ No <br /> 6. BARRIERS alongRigbt-of•Way <br /> 7. DITCH Yes ❑ No IfYes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»>»[»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Lith of Pque Regaircd: Ft and Diameterof Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Tom (With proposed) Total Number of Storm Drams Islets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Ming Fed in tength and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> F' Id Inspection <br /> Driveway w/or w/o pipe................................................$95.00 ElPaved frontage. ...._. ._. ._..... ..$100.00+0.46/ft <br /> Drivewayw/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CounteAComputer,c:\AccessV4*1ication for Permils0riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />