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THE APPLICANT HEREBY CERTHIEES: <br /> 1. That he/she has read all the provisions of this op tion,and that the description included in this application arc correct to the best of his/her <br /> knowhvrdge;and <br /> 2. That halshe is the owner of the respective property,or is qualified to refit the owne,and <br /> 3. That hehhe will assume full responsibility for all liability far personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of h s&w failure to do the worts provided herem;and <br /> 4. That in the event any claim of such liability is made against the County of San Joagiwt or any departnw3t,official or employee thereof he shall <br /> defend,indemnify and holdthem and each of them harmless for such claim;and <br /> 5. That work shall be peafoined by the applicant and/or any representative of the applicant in the <br /> County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Pamit;and <br /> 6. That if permission is as requested,he agrees to do the wade described in accordance with all temrs,conditions and restriction of this and any <br /> attached sheet, general a III provisions. <br /> ofApplicaat TMe "Daft <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Pavod(poor) ❑ Paved(Good) <br /> 2. SLOPING: Away from Pavan at ❑ Towards Pavanant ❑ Flat <br /> 3: PIPES: Now Egg-Type <br /> Other Pipes in nagbborhood: Yes ❑ No Approaches ❑ Crow Drain ❑ Sim <br /> Atfadrment to neiglibo's pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S. ASPSALT CONCRETE DIICL: Yes ❑ No <br /> 6. BARRIERS alongRW-of-Way <br /> 1. DITCH Yes ❑ No Af Ifyes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»»»»»»»»»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR It MMERCIAL ❑ A.GRTCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mia.Depth A.C.over "M.Depth 3/4"A.B. <br /> Notes <br /> L PIPES: L-9th of Pipe Regairod: FL and Diaauter of Pipe — hich <br /> To be connected to any adjacent driveway pipe Yes No ILy <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Tom (-ith proper) Total Numther of Storm Drain Inlets <br /> Notes <br /> E: <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "1 fim Depth AC.over "Min.Depth 3/4"AB. <br /> Meng Fed in kagfh and Fed is width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field 'ot <br /> Driveway./or w/o pipe......... ... ..._.__...___.._ 595.E ❑Pavedfraatage.._._._.... _._.._..._..5100.40+0.46/R <br /> ❑Driveway w/box Calvert.............................._.................$155.00 ❑Curb,Gutter,sidewalk..........._..........$140.00+0.98/ft <br /> CounteAcompirter,c:1A MkAppliaatior for PermitADriveway and Paved Fruitage Page.2 of 2 Revised 8/2000 <br />