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TIDE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description included is this application are correct to the best of his/her <br /> knowhvdge;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 responsibility fat all liability far personal injury or damage to Property whk hmay arise out of the 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 Jbagiun or any depmtraeaf,official or employee thereof;he shall <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Perms and <br /> 6. That if permission is granted as rock,he agrees to do the work described in accordance with all terms,conditions and restriction ofthis and any <br /> attar*d s)xeet,included as general <br /> �of/special I11 provisions. <br /> � -oV <br /> Signffiare of-Applicau-T9le Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»>F»»EM STING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ out ❑ Gravel ❑ Aggregate Base ❑ Paved(poat) ❑ Paved(Good) VAL <br /> 2. SLOPING: Away from Pavamam ❑ Towards pavement [ Flat ❑ <br /> 3. PIPES: Now 4f— Existing-Type <br /> Odwpipes inneighborhood: Yes ❑ No M Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETED Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 1. DITCH Yes ❑ No 6M IfYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»PERMIT REQUIREI/ENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 ")trfio.Depth A.C,over Mm.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Lemglh ofPipe Re;gairod: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No 4 <br /> Total Length: (with proposed) Tatai Number of Storm Dram Inlefa <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "hfi A.C.over "Mhn 3/4"A.B. <br /> Measuring Feet in length and Fed in width <br /> FEES <br /> Driveway Fncaoachmad Permit base fee............................$85.00 <br /> Field Inspection <br /> Drivewayw/or w/o pip e..........................._. .___$95.00 ❑Paved _..........$100.00+0.46/ft <br /> Driveway w/box Calvert........_......................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100:00+0.98/ft <br /> Counter\Computer,c: \Apphcation for PemutslDnveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />