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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 included in thisr <br /> application are wired to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or dam to ply which may arise out of the work described above, <br /> or which may arise oMu oThm&er 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 Joagiva of any department,Ofkial <br /> of defend,indeamify and hold them and each of them harmless for such claim;and employee thereof he shall <br /> 5. That work shall be performed by the applicant and/or any representative of the <br /> applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County EuMac4nuouR Peace and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all <br /> attache �>o�ditions and restriction of this and any <br /> �IhuKdWed -�specWII provisions._ <br /> Signal=ofTr <br /> Applicant-Tide Date'7`�'"�`4L <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»>»»»»»»»»»»»EKISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None K Dirt ❑ F Gravel <br /> ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: A�Pavement Towards Pavement E] Flat ❑ <br /> 3. PIPES: None Eg-Tyle <br /> Other pipes in t borhood: Yes ❑ No—T Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6` BARRIERS along Rrght'c1-Way <br /> 7. DITCH Yes ❑ No If Yes: V We ❑ 2 Point ❑ Other <br /> ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE <br /> ❑ INDUSTRIAL ❑ <br /> PAVED with Z " <br /> Min.Depth A.C.over �_,�Min.Depdk 3/4"AB. <br /> Notes <br /> L PIPES: L-gth of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No J^�}Z -- <br /> Tom (with proposed) Total Number of Storm Draln Inlets <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Mpg ---- Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85. <br /> ie Inspection <br /> veway w/or w/o pipe.......................................... .!F55.00 <br /> ❑Paved& <br /> °mage................._............._$100.00+0.46/ft <br /> Driveway w/box C�rlverL............................................. <br /> ❑Curb,Gutter,Sidewalk.......................$140.00+0.98/ft <br /> Counter\Computer,c:\Acoess\Apphcation for Permits\Driveway and Paved Frontage P 2 of 2 <br /> �° Revised 8/2000 <br />