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THE APPLICANT HEREBY CERTHIES: <br /> 1. That he/she has read all the provisions of this application,and that the description inchrded iu this application are correct to the best of his/her <br /> knowlwdge,and <br /> 2. That lie/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will ass" me full respams+i7ity for all liability far personal injury or <br /> damage to property whish may arise out of the work described above, <br /> or which may arise out of his/her faaure 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 eavloyee theaeog be shall <br /> defend,indemnify and hold them and each of thein nameless for such claim;and <br /> 5. That work shall be perfonued by the applicant and/or any eve of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachnient pmnit;and <br /> 6. That if pe 'on is grained requested,he agrees to do the wok described in accordance with all.temps,conditions and restriction of this and any <br /> attache t,included provisions. <br /> ffV//.., S' ofd-Tffie Date[/ <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ oat Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ PavekGood) ❑ <br /> 2. SLOPING. Away frnnm Pavement ❑ Towards Pavanes t ❑ Flat <br /> 3. PIPES: NOW ❑ ` Type _1 Q t✓b�(��E i E Pl trt- <br /> Other piper in Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attac>zment to ne~s pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DRCE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes X No ❑ Ifyos: V we 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»»»»»»»»»»»»»>PERMITREQUIRE1dENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with _"Min.Depth A.C.over �_"W.Depth 3/4"A.B. <br /> Notes <br /> L PIPE& length of Pipe Require& Ft and Diameter of Pipe imh <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total (-Mpropo-d) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes R No <br /> 4. PAVED FRONTAGE: PAVED with "lain.Depth AC.over "!vim.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet is width <br /> FEES <br /> Driveway Encroach Peamit base fee............................$85.00 <br /> aeid Inspection <br /> ACZ)Driveway w/or w/o pipe............................ _.._...__$95.OD ❑Paved finatage�.. _. __. ... $100.00+0.46/ft <br /> ❑Driveway w/box Culvert-........_......................._.............$155.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.98/R <br /> Counter\CaMuter,cAAccesslApplioation for PermitsNaiveway and Paved Frontage Pap of 2 Revised 8!2000 <br />