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THE APPLICANT HEREBY CERTHUSc <br /> 1. That ho(she bas read all the provisions of this application,and that the desadptioa iuchided MtW application are correct to the bast of his/her <br /> knowhvdgc,and <br /> 2. That he/she is the owner of the respective property,or is gwMod to represent the owner,and <br /> 3. That he/she will assume full respansiWity for all liab"4 farpersonai i*ay or damage to property which may arise out oftho work dela bed above, <br /> or which may arise out of hisf%ar failure to do the work provk1od herein-,and <br /> 4. That in the event anY claim of such hab'lily Is made againd 1heConaty of Sm hist}imn of any depmtaaent,official or employee thereo&he shall <br /> Mend,mdenmify and hold Wem and each o(them harmless for such claiug,and <br /> 5. That work shall be performed by the applicant and/or any representative of The applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin Comely Encroachment Pe d&,and <br /> b. That if permission is granted as requested,he agrees to do the wo&descnW in acoordance with all teams,conditions and restriction ofthia and any <br /> attached sheet,included as gensai or mal III provisions. <br /> Signature ofd TMe, Date <br /> FIELD INSPECTOR CO11dItH:N'1*S <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDITIOiNS«««««««««««««««««««« <br /> L DRIVEWAY: Nene ❑ Dut 9 Gravel ❑ Aggregate Base ❑ Paved(po-) ❑ Pavad(Good) ❑ <br /> 3.SLOPING: Avmyfmm Pavom o t ❑ Towards Pavmm ❑ Flat <br /> 3. PIPEti• Now E9 Eiddng-Type <br /> Other pipes ianeighborhood: Yes El No <br /> Approaches El Cross Dram ❑ Sim <br /> Attachment to neigbboes pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S ASPHALT CONCRETE DUO: Yea ❑ No 0 <br /> 6..RARREMS alc og Right-of-Way <br /> 1. DITCH Yes ❑ No [2 IfYes: V We ❑ 2 Point ❑ Other ❑ VrWffi Depth <br /> »»»»»»»»»»»»»»»»»»PERMITREQrmruMENTS«<<<<< ««««««««««««« <br /> 1. DRIVEWAY: SFR Cff COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "h4k.Depth A.C.over Mim.Depth 3/4"A.B. <br /> Nates <br /> 2. PD'E5k Largth of Pipe Regairod - PL=4 Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No 0 <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: (with proposed) Total Number of Star=Dnrda Inlds <br /> Notes <br /> 3. 1309ADWALL Yea ® No <br /> 4. PAVED MONTAGE: PAVED with "Max Depth A.C.over "&1m.Depth 3/4"A.B. <br /> Measuring Fed in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe......... :.._._ __.... ____ _$95.00 ❑Paved frontago..._—-----_._...__....$100.00+4.46/& <br /> ❑ Drivowayw/boxCnlveR._. .. _.........._.._._...._.... _..$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.99/R <br /> CounterlGmnputer,c-Mcc=Vpplioafion for Permits0ripeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />