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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this appon,and that the description imrchrded amthffi application are correct to the best of his/her <br /> knowtvv lge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owme,and <br /> 3. That he/she will assume full responsibility for all Liability for personal injcuy or damage to property which may arise out ofthe work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made asst the Comity of San <br /> Jbagiima or any department official or employee theaeol;he shall <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Right-0f--Way at the above indicated site <br /> with a valid San Joaquin County Encroacliment Pnnmit;and <br /> 6. That if Perm <br /> is granted as requested,he agrees to do the work described in accordance with all tarts,conditions and restcictim of this and any <br /> attacheddederr special III provisions. <br /> �07 <br /> Signature ofApplic a t_Tide Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> c <br /> L DRIVEWAY: None ❑ Vitt ❑ (travel ❑ Aggregate Base ❑ Pave KP.W) ❑ Paved(Good) JV <br /> 2. SLOPING_ Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None Existing-Type <br /> P►P�in k Yes ❑ No Approaches ❑ Cruse Drain ❑ Sin <br /> Attadmeat to neightwes Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S ASPSALT CONCRETE DACE: Yea ❑ No <br /> 6. BARRIERS slang Right-cf Way <br /> 1. DITCH Yes ❑ No ik Ifyes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»>?»PERMIT REQUIREIMM«««««««««««««««««««« <br /> 1_DRIVEWAY: SFR ❑ COMMERCIAL AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED wpm "Min.Depth A.C.over _�_"Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPE& Length of Pipe Required: Ft.and Diameter-of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No�_ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total : (with per) Total Nmmber of Storm Drain Inlets <br /> Notes F-. <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED worth "Mm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Meng Feet in length and Feet in wilt <br /> PEES <br /> Driveway Encroachment Perrmit base fee........................ ..$85.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe............................................$95.00 Pervert fi+ontage._._.._.._....__.__....._.._$I00.00+0.46/ft <br /> ❑Driveway w/boxCulvert-............................................$155.00 Crub, <br /> (4nlber,4;idewmac................. <br /> ....$100.00 <br /> Counter\Computer,c.Mccess\Applieation for Pamits0liveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br />