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TILE APPLICANT MREBY�CEof RT S:and that the ckscripttiofl sal ind&application are correct to the best of h-ber <br /> m <br /> I. That he/she has ad all the pro <br /> knowlwdge-,and � ed to represent the owner,and <br /> 2. That he/she is the owner of the respective property,a'is qualified <br /> ��or damage to PTOP�3` <br /> which may out of the work described above, <br /> 3. That helshe will assume full responsibility f°r all liability p <br /> or which may arise out ofiris/her <br /> failure to do the work Provided herein;and <br /> official or employee thereof;he shall <br /> 4. That in the event any claim of such liability is made against the��,of San Joagiun or auy dept <br /> defend,indemnify and hold them and each of them harnhless for such claim;and <br /> vie of the applicant in the County Rrgl�'of Way at the above indicated site <br /> 5, That work shall be performed by the applicant mor any�h <br /> with a valid San Joaquin County Encao <br /> Permit;and with all terms,conditions and restriction of this and any <br /> . agees to do the work described in accordance6. That if,gett�hrs on is r"or special III pr ons. <br /> aimched sheet,inc ly6 <br /> Die <br /> - <br /> -Titl <br /> Signatcrre of App e <br /> FIELD INSPECTOR CONMNTS <br /> «««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»EXIS'fII�1G CONDITIONS e ❑ Dirt � Paved(poor) 11paved(Good)paved(Good) El <br /> Gravel °Base El 1. DRIVEWAY: NonFlat El2. SLOPING: <br /> Away from Pavement Towards Pavement ❑ <br /> None -Type ❑ Cross Drain ❑ Size <br /> 3. PIPES: � Approaclies <br /> Other'pipes m neighborh°°d' <br /> Yes ❑ No <br /> Attachment to neighbors Pipe: <br /> Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS long Rio-of-Way �I Other El width th <br /> -- <br /> Yes ❑ No lA IfYes: V Style ❑ 2 Point ❑ <br /> 7. DITCH «««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTSAGRICULTURE El /4' <br /> ❑ <br /> SFR [, COMWRCIAL ❑ <br /> 1. DRIVEWAY: ��Min.Depth 3/4"A.B. <br /> PAVED with Z---•"Min.leper A.C.over _ <br /> Notes <br /> Ft.and Dia U0W of Pipe --� <br /> Z. PIPES: Leuglh of Pipe Required: __________ EJ <br /> pipe Yes [9 No <br /> Tobe connected to any adjacent ❑ <br /> DRAINAGE INLET REQUIRED Yes <br /> No 54 <br /> (with ) Total Number of Storm Drams Web <br /> Total Length: _,�------ <br /> Notes <br /> 3. HEADWALL Yes ® NO "Min Depth 3/4"A.B. <br /> "Min,Depth A.C.over �._. <br /> 4. PAVED FRONTAGE: PAVED with Feet in width <br /> Measuring Feet in length and <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection $100.00+0.46/ft <br /> $95.00 El &arrtage............_...._.............•..$100.00+0.98/ft <br /> ❑ Driveway w/or w/o pipe.................._......._..._............... ❑Curb,Gutter,Sidewalk................... <br /> ....:.................$i 55.00 <br /> ❑ Driveway w/box Culvert-.......................... Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\APplication for Permits\Driveway and Paved Frontage <br />