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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has mead all the provisions of this application,and that the description included mi this,application ate correct to the beat of his/her <br /> knowlwdge,and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent the owned and <br /> 3. That he/she will assume full responsibility for all liability far personal injury or damage to property whirr may arise out ofthe work described above, <br /> or which may arise out of h6lher failure to do the work provided herein,and <br /> 4. That in the event any claim of such liability is made against fBe County of San Riacpun or any dqx tmeut official or <br /> employee thereot he snail <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the am a or ei>tstiVe of the applicant in the County Rigbt-of-Way at the above indicated site <br /> with a valid San Joaquin County En,rro eanit;and <br /> 6. That if permission is graded as do the descnW in aooerdance with all terms,conditions and restriction ofthis and any <br /> attached sheet,included as <br /> Si mtlC <br /> FIELD SPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»» CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel [ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> Z. SLOPING: Away from Pavement ❑ Towards Pavmreot ❑ Flat <br /> 3: PIPES- Now .d Existing-Type <br /> Other pipes is nei0bodm&- Yes ❑ No [� Approaches ❑ Cross Drain ❑ Sin C� <br /> At#ad ed to neighbor's Yes El No <br /> 4. HEADWALL: Yes ❑ No' <br /> S. ASPBALT CONCRETE DEM: Yes ❑ No <br /> 6. BARRIERS along Rigbr-af Way <br /> 1. DITCH Yes ❑ No IfYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»PERMITREQUIREMENTS«««««««««««««««««««« <br /> 1_DRIVEWAY: SFR COMMERCIAL ❑ AGOCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Jct "Min Depth A.C.over —I-- "Ism,Depth 3/4"A.B. <br /> Notes <br /> L PIPE& Length of Pipe Required: Ft.and Diaaa.eter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes AN, <br /> DRAINAGE INT.ET REQUIRED Yes ❑ No <br /> Toil : (-M proposed) Total Number orStorm Drift I is <br /> Notes <br /> 3. HEADWALL Yea ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia.Dep1h3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85.00 <br /> Fielh'on <br /> Ifs Driveway w/or w/o pipe..........................._..........___$95.00 ❑Paved&mtage__. ...._._ __...._ .$I00.00+0.46/ft <br /> ❑ <br /> Driveway w/boxCulvert........_........................._......._..$155.00 ❑Curb,Gutta,Sidewalk.......................$100.00+0.98/& <br /> Coudae Computef,c:VccesslApplieatimr for Pe mits0riveway and Paved Frontage Paga.2 of 2 Revised 8/1000 <br />