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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she las read all the provisions of this application,and that the description included in this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective properly,or is qualified to rpt the owner and <br /> 3. That he/she will assume full responsibility for all liability for personal nyury or damage to property which may arise out of the 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 against the County of San Ibagiun or any departineut official or <br /> employee thereof;he shall <br /> defend,indemnify and hold them and each of them harmless for such clam 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 Eft Permit;and <br /> 6. That if pe is granted asto do the wak described in acoordance with all terms,conditions and restriction of this and any <br /> attached included as or <br /> al <br /> visions. <br /> x "006 <br /> Si of licand Title Date <br /> FIELD INSPECTOR COMMENTS <br /> ENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> t <br /> L DRIVEWAY: None ❑ lain [] Gravel Aggregate Base ❑ Pave ki—) ❑ Pavod(Good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavemew ❑ Flat ❑ <br /> 3. PIPES: Now ❑ Eich -Type <br /> Other pipes in neighborhood: Yes No El Approaches ElCross Drain F-1Size <br /> Atfachmmt to neighbor's pipe: Yes ❑ No fl <br /> 4. HEADWALL: Yes ❑ No' k <br /> S. ASPBALT CONCRETE DIKE: Yes ❑ No 1A1, <br /> 6. BARRIERS along Right-oWN0 <br /> 7. DITCH Yes ❑ Ifyes: V We 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREIdENTS««««««««««««««««a«««< <br /> 1. DRIVEWAY: SFR k_/ COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPES: I-&*of Pipe Required: FL and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length. (with proposed) Total Number orStarm Dram Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mm.Depth 3/4"A.B. <br /> Measuring Feet in kngth and Fed in width <br /> FEES <br /> i <br /> vew y Encroachment Permit base flee....................... ...$85.00 <br /> 'on <br /> Driveway w/or w/o pipe.............................._...._._... ..$95. ❑Paved frmtage---------------__._...........$100.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................ 5.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> Counter\Computer,c:lAccess\Application for permitslDriveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />