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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions ofthis Dov,,and that the desmiptioa mcloded intim application we correct to the beat of his/her <br /> knowlvdV,and <br /> 2. That helshe is the owner of the respective property,or is qualified to reprep the owner;and <br /> 3. That he/she will assume full responsa�ity for all lia3>t7ity farprraorui mjtxy ordawne to property which may arias out ofthe work desrn'bed above, <br /> or which may arise out of his/her failure to do the work provided hetain,and <br /> 4. That m the event any claim of such liabil'dy is made apinA the County of San Amgina or any deparknent,official or employee thereon;he shall <br /> defend,indemnify and holdthem and each of them harmless for such claim;and <br /> 5. That work shalt be performed by the applicant and/or any representative ofthe applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment ent Permit and <br /> b. That if permission is granted as he agrecs to do the work descrind in acoo dance with all terms,conditions and restriction ofthis and any. <br /> attacbed sheet, as special III provisions. <br /> XI <br /> sig a--of-4PH mut-Tilt- Da& <br /> FIELD INSPECTOR COAUKE 1TS <br /> »»»>> »>>>>>>>>>>>>>>>>>>>>>>>>>>>>>EXt'SIING CONDITIONS«««««««««««««««««««« <br /> L DRI SWAY: Now ® Dart ❑ Gmvnl ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2.SLOPING: Away 1kom Pavmmeat ❑ Toanrds Pavement ❑ Flat <br /> 3.' PIPES: Nora Existing-Type <br /> Other pipes in>d*&odxxxk Yea ❑ No Approaches ❑ Crosa Drain ❑ Sine <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4.HEADWALL: Yea ❑ No' IN <br /> S.ASPHALT CONCRETED Yea ❑ No 9 <br /> 6..BARRIERS alangRight-of-Way <br /> 1. DTTCH Yea ❑ No [9 If Yes: V Style ❑ 2 Poi ❑ Otho. ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»» <br /> PERMIT REQUIREMENTS««««««««««««««««z«««< <br /> L DRIVEWAY: SFR COMMERCIAL ❑ AGRiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2► "Mm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& I mgth of Pipe Regoirod: Pt.and Diamatcr of Pipe Tach <br /> To be connected to my adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Imgth: (with proposed) Todd Nmuber of Storm Drda Inlets <br /> Nates <br /> 3. HEADWALL Yes no No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "Mm.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................585.00 <br /> FietdInapection <br /> Driveway w/or w/o pipe......._...... ._...._..._.. ___595.00 ❑Paved fr outage__.__._.__ _.._-- 510000+0.46/& <br /> ❑Driveway w/boxCulvert._.._....................__..._...........5155.00 ❑Curb,gutter,Sidewalk.......................$100.00+0.98/R <br /> CourtakCamputer,c:44cce8sVffhoation for Permits0riveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br /> t � <br />