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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has read all the provisions of this application,and that the description k*Wed inthis application are correct to the best of his/her <br /> knowlwdge;and ' <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owned and <br /> 3. That he/she will assume full responsihility for all liability far Pas"al injury or damage toproperty which may arise out of the wodc described above, <br /> or which may arise out of his/her failure to do the work providod herein;and <br /> 4. That in the event any claim of such liability is made against the County.of San Jbagi im or any dem,oTkisl oree <br /> errgmloy thereoiy he shall <br /> defend,indemnify and hold them and each of them harmless for sex9n claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant m the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Eumachment pmt and <br /> 6. That if permission is granted as requested,he agrees to do the work described in aceadance with all <br /> tams,conditions and restriction of this and any <br /> tddatamrhaas a 'a1ffi provisions. <br /> Signature <br /> i 6 <br /> of Applicant-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> ����������������������»���»�»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfrom Pavanent ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None A Existing_Tye <br /> OtherPiPes inneigbborhood; Yes ❑ No Approaches ❑ Cross Drain <br /> Size <br /> Attachment to neighbor's ❑ <br /> 4. HEADWALL: Yes ❑ Yes ❑ No No Xr/�S- <br /> s. ASPHALT CONCRETE DUO: Yes ❑ No. <br /> 6. BARRIERS along Right-of•Way <br /> 7. DITCH Yes ❑ NoIMIf Yes: V Style ❑ 2 Point ❑ Other, ❑ Width Depth <br /> »>»»»»»»»»»»»»»»>»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR comwlERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Min.Depth AC.over <br /> _ Min Depth 3/4"A.B. <br /> Notes E7 <br /> 2. PIPES: Length of Pipe Required: It and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Itf <br /> Tom Iangth: (�proposed) Total Nurnher of Storm Drat$Inlets <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with -"Min Depth A.C.over <br /> "Min.Depth 3/4"AB. <br /> Mpg Fent in length and Feet in width <br /> Driveway Encroachment Permit base fee............................$85.00 FEES <br /> Fiel hon <br /> Driveway w/or w/o pipe................................. $95.00 ❑Paved fi Dotage <br /> $100.00+0.46/ft <br /> Driveway w/box Culvert.................................................$155.00 <br /> El curb,Datta;Sidewalk.......................$1fl0.00+0.98/ft <br /> CounteAComputer,c:kAccess\Applieation for PamitslDriveway and Paved Frontage Page Z of 2 <br /> Revised 8/2000 <br />