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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description indu&d in this application ate domed to the best of his/her <br /> knowlwdge;and <br /> 2. That heJshe is the owner of the respective property,or is qualified to represent the owl and <br /> 3. That he(she will assume full responsibRity for all liability 6m Pftsonai injury or damage to proPedY which may arise out of the work described above, <br /> or which may arise out of hisAw failure to do the wort:provided herein,and <br /> 4. That in the event any claim of such liability is made against the Coudy of SanAmqmor any department,official or employee thereat;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 applic a*and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Pew and <br /> b. That if permission is as requested,he agrees to do the work described in acocrdance with all terms,conditions and restriction of this and any <br /> attached sheet,' a. rapeei provisions. <br /> Signaftw of t{pplicaut-T910 <br /> FIELD INSPECTOR COM&IENTS <br /> Z>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>MOSTING,CONDMOM«<<<<<<««««««««««««« <br /> 1. DRIVEWAY: None El out ` Gravel <br /> ❑ AMgd.Base ❑ ) ❑ Paved(Csood) ❑ <br /> 2. SLOPING: A ayfium Pavement [] Towards Pavement EJ Flat <br /> ne <br /> 3. PIPES: NoExisting-Type <br /> Other pipes innei chood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Aitac4rmeat to Yes El No <br /> 4. HEADWALL: Yes ❑ No' ' <br /> S. ASPSALT CONCRETE DMM: Yes ❑ No <br /> 6. BARRIERS a{anSRigfitc&Way <br /> 1. DITCH Ya ❑ No Ifyes: V Style ❑ 2 point ❑ Other <br /> ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»>>>>PERMITREQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SIR ��--77 COMMERCIAL, ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with - "Min.Dopes A.C.over _•rn,Depth 3/4"AR <br /> Notes <br /> 2. PIPES: Io£Pipe Required Pt and Diameter of pipe Inch <br /> To be c000ecW to any adjacent driveway pipe Yes No <br /> DRAINAGE INLETREQUIRED Yes ❑ No <br /> Total —(with proposed) Total Nundw of Storer Drade Inlets <br /> Notes <br /> F-- <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with -"Mm Depth A.C.over " <br /> Min.Dep1h3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> Driveway Encroachment Permit base fee............................$85.00 FEES <br /> i d Inspection <br /> MEakiveway w/or w/o pipe........__:.._...........__.__. ---__$93170 ❑Paved <br /> .. w.S100.00+0.46/ft <br /> ❑Driveway w/box Culvert.........................................$155.00 <br /> _........_. ❑Curb,Gutter,Sidewalk...............—.$100.00 <br /> +0.98/R <br /> CountellCompute r,cAAccesslApplieation for Pemnits0riveway and Paved Frontage Paga.2 of 2 <br /> Revised 8/2000 <br />