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THE APPLICANT IIEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this Vplicxkiov�and that the descxiptioa included inthis application am correct to the best of his/her <br /> knowlwdgr,,and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent the-owner,and <br /> 3. That he/she will assume fall respondhiity for all liability for personal injuryor 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]bagim or my department official or employee thereat 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 in the County Right-of-way at the above indicated site <br /> with a valid San Joaquin County Encroachment Pemuit;and <br /> 6. That if permission is granted as requested,he agrees to do the work descr'bai in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,includeluvaeral.as special III provisions. <br /> Signmtrm ofApplic aal4ide Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTIriG CONDITIONS«««««««««««««««««««« <br /> t <br /> 1. DRIVEWAY: None ❑ Dint Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfrom P v..t Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: Now Existing-Type _ <br /> Other pipes in nei0bodwod Yes ❑ No JM Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbors pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No 1 , <br /> S ASPHALT CONCRETE DIIfE: Yes ❑ No <br /> 6..BARRIERS along M*-of--Way <br /> 7. DITCH Yes ❑ No IfYes: V Style ❑ 2 Point ❑ Ofher ❑ VrW& Depth <br /> »»>>>>> »»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with z.- "Wm.Depth A.C.over A "Min.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe inch <br /> To be connected to any adjacent driveway pipe Yes ❑p No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: (with proposed) Total Number of Storax Drd n Latera <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "Mm.Depth 3/4"AB. <br /> Measuring Fed in length and Feet in width <br /> FEES <br /> Driveway Encroachment Pemit base fee....................... ..585.00 <br /> Field inspection <br /> y w/or w/o pipe................. - ❑Paved $100.00+0.46/ft <br /> $+outage..._...._._.__.....__.... <br /> ❑Driveway w/box Culvert........._..............................._.$155.00 ❑Curb,Gutter,Sidewa&......................$100.00+0.98/ft <br /> CountaAComputer,cAAcceseWplication for Permits0riveway and Paved Frottage Page.2 of 2 Revised 8/2000 <br /> i <br /> r <br />