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THE APPLICANT HEREBY CERTIFIES: -. <br /> 1. That he/she has read alt the provisions of this appficatiaq and that the description inchxled iathis application ate correct to the hast of his/her <br /> knowlvadge,and <br /> 2. That hal he is the owner of the remove property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full msponaibi1ity far all halniity for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of bis/her failure to do the work provided heroin;and <br /> 4. That in the event any claim of such liabilky is made against the County of San Jbagam or any depaatreent,official or employee thereof;he shall <br /> defend,indemnify and holdthem and each of them harmless for such claire;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 sits <br /> with a valid San Joaqain County Fit Perms and <br /> S. That if permission is granted as requested,he agrees to do the wart described in accordance with all teams,conditions and restriction of this and any <br /> bed sheet,included as of special 111 provisions. <br /> )q a � �-- �v P —i -C>co <br /> Signature-of Applicaut Tine Date <br /> FIELD INSPECTOR CO1 MMATS <br /> »»»»»»»»»»»»»»»»»»»»EMSTMG CON=ONS«««««««««««««««««««« <br /> e <br /> L DRIVEWAY: Nage ❑ hitt ❑ Gravel AW"ate Base ❑ Paved(paor) ❑ Paved(Good) ❑ <br /> 2- SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES- Now ❑ E>nsGeg-Type 1 Z., eborm4vt a-e <br /> Other pipes is neighborhood:- Yes Ile No ❑ App poaches ik Cross Drain ❑ Sine I-_CY.___I <br /> Attachment to neighhor's Yes No ❑ <br /> 4. HEADWALL: Yes ❑ No' It <br /> S: ASPHALT CONCRETE Dl7CE: Yes ❑ No <br /> 6. BARRIERS slang Rigbt-of Way <br /> 7. DITCH Yea Pd No ❑ IfYes: V Style 6t2Pburt ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»PERMIT RF.QUERE1031M«««««««««««««««««««« <br /> 1_DRIVEWAY: SFR COMMERCIAL ❑ ACsRiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with N&L Depth A.C.aver '� "hfwn Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Required Ft.and Diameter of Pipe Inch <br /> To be connected to arty adjaou t driveway pipe Yea K-No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Starer Drain Inlets <br /> Notes <br /> 1-7- <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "11Sm Dgrth A.C.over "Mia.Depth 3/4"A.B. <br /> Measuring Feet in lean &and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85.00 <br /> Field 'on <br /> y w/or w/o pipe............_....... ___$9S.DD ❑Paved <br /> •••----• fra�atage.__...._....__......_..._..$100.00+0.46/ft <br /> ❑ Dfivowayw/boxCulvert................................._......._.$155.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.9&2 <br /> CountaiComputer,c:\Access\Application for Permits0riveway and Paved Frontage Pap.2 of 2 Revised 8/2000 <br />