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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this applicationi and that the description inchded in this application are correct to the best of his/her <br /> knowhwlge,and <br /> 2. That he/she is the owner of the respective property,cc is qualified to represeirt the owner;and <br /> 3. That he/she will assume full responsibility for all liabUity for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out ofh61w failure to do the work provided herein;and <br /> 4. Thal in the event any claim of such liability is made against the Courcy of San Joagim or my depwiment,official or employee tlxreoi he shall <br /> defend,indemnify and holdthe ,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 in the Coumiy Rigld.-of-way at the above indicated site <br /> with a valid San Joaquin County Encroadana t Permit and <br /> 6. That if pennissicn is as requested,ha agrees to do 13te work described in accordance with all temps,conditions and restriction of this and any <br /> attached III provisions. <br /> -V7 31.0 6 <br /> ignature of Applicssht Tile Date <br /> FIELD INSPECTOR COIN S <br /> EXLST NO CONDMONS«««««««««««««««««««« <br /> L DRftWAY: None J, Dirt ❑ Gravel ❑ Agee Base ❑ ftvi(P-) ❑ Pavea(coed) ❑ <br /> 2. SLOPING: Away from Pavy mot Towards Pavement ❑ Flat ❑ <br /> 3. PIPES- NapeEgg-Type <br /> Other pipes in Yes ❑ No Approaches ❑ cross Drain ❑ Size <br /> Attattoneigbbor's Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S. ASPHALT CONCRETE DIKE: �"Yeses El No <br /> VN <br /> 6. BARRIERS alongRi&-c&Way <br /> 1. DITCH Yes ❑ No If-Yes V We ❑ 2 Foist ❑ CKher ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS<z««««««««««««««««««« <br /> 1. DRIVEWAY: SFR_ COMMERCIAL ❑ RtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with _"Miam.Depth AC.over _"Mm.Depth 3/4"A.B. <br /> Notes <br /> L PIPE& L-Sth of Pipe Rapirod Ft.and Disum6w of Pipe Inch <br /> To be connected to any adjacci t driveway pipe Yes ❑l No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total length: (with proposed) Total Number of Storm Drabs Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "tarn.Depth AC.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee......................... .589.00 <br /> Field 'on <br /> Driveway w/or w/o pipe.......... _....... .. . ....._. 595_ ❑Paved frontage........._...._....._.._.._..5100.00+0.46/ft <br /> ❑Driveway wus,c lyort........._................... .... ......_.. ❑Curb,Gutter,Sidewalk.......................S10o.00+0.98/ft <br /> Counter\Computer,c:lAccw\Application for PermitsUkiveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> 1 <br />