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THE APPLICANT HEREBY CERTH IT'S: t hatthe desesipticne is�hTded in this application are correct to the best of his/her <br /> 1. That he/she has read all the provisions of tins application, <br /> and knowlwdgv,and <br /> qualified to and <br /> 2. That,he/she is the owner of the respective property, to or is �y which may arise out of the work described above, <br /> will assume fall responsibility for all liability for personal injury or damage <br /> 3. That he/she PSP <br /> provided herein;and <br /> or which may arise out of his/her failure to do the work <br /> the County of San Joaq�n or any �official or employee thereof;he shall <br /> 4. That in the event any claim of such liabifity is made against for such claim,and <br /> defend,indemnify and hold them and each of them harmless of the applicant in the County Right-of Way at the above indicated site <br /> 5, That work shall be performed by the applicant and/or any representative <br /> with a valid San Joaquin County E=oachrnent Permit'andworkall terms,conditions and restriction of this and any <br /> 6. That if permission is granted as requeste4 he agrees to <br /> do the work described in accordance <br /> attached sheet,included as general m ecial III provisions. <br /> rA4 e4!!� Date <br /> Signature ofAppficant-Title <br /> FIELD INSPECTOR COMAIENT5 <br /> »����»��������������������»»»»»»EXISTING CONDITIONS«««««<<<<<<««««««««« <br /> None ❑ Dirt ❑ Gravel X, �Base ❑ <br /> Paved(poor) ❑ Paved(Good) ❑ <br /> 1. DRIVEWAY: Flat ❑ <br /> 2. Si3OPING: <br /> Away from Pavement ❑ Towards Pavement <br /> 3. PIPES: None ❑ Exusfmg-Type <br /> Other pips in neighborhood: <br /> Yes -❑ No <br /> ❑ Cross Drain ❑ Size <br /> Attachment.to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DOM. Yes ❑ No <br /> 6. BARRIERS along Right-°f�'-W,a/y <br /> Yes L� No Other ❑ With <br /> Depth <br /> 7. DITCH ❑ IfYes: V Style 2 Point ❑ <br /> »>'»>,»>'»»>,»��»»��»�»�»����PERMIT REQUIREMENTS«««««««««««««««««««« <br /> COMMERCIAL ❑ AGRICULTURE F] INDUSTRIAL El1. DRIVEWAY: SFR <br /> PAVED with <br /> �"Min.Depth A C.over "Min Depth 314"A.B. <br /> Notes <br /> Ft.and Diameter of Pipe Ii <br /> 2 PIPES: Length of Pipe Rwpkod• -- <br /> To be eoanected to any adjacent driveway pip Yes El No <br /> DRAINAGE INLET REQUIRED Yes ElNo <br /> Total (with per) Total Number of Storm Drs's Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No [ <br /> "Min.Depth A.C.over "Min.Depth 314"A.B. <br /> 4. PAVED FRONTAGE: PAVED with -- <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection ❑$95.00 Paved frontage........._......._....._......-S100.00+0.46/ft <br /> ❑ Driveway wl or w/o pipe........................._.._................... Curb,��,Sidewalk......................5140.00+0.98/ft <br /> ❑ Drvsway w/box Culvert_.............. <br /> .................................$155.00 <br /> Pa 2 of 2 Revised 8!2000 <br /> ce <br /> Counter\Computer,c:\,& \Appticatron for Permits\Driveway and Paved Frontage Se <br />