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THE APPLICANT HEREBY CERTIFIES: that the descaiption ir� <br /> I, That he/she has read all the in this application are correct to the best of his/her <br /> provisions of this applioation,and <br /> knowhudgv,and <br /> 2. That he/she is the owner of the respective property,or is qualrfted to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for personal injury <br /> or damage to property��may arise out of the work described above, <br /> or which may arise out of his/her failure to do the wait provided herein;and thereon;he shall <br /> 4. That in the event any claim of such liability is made against <br /> the County of San Joagian or any�° °r employee <br /> defend,indemnify and hold them and each of them harmless for such claim;and cant m the County Right-of-Way at the above indicated site <br /> performed by app• ve of the appli <br /> 5. That work shall be pert the Lard and/or any <br /> with a valid San Joaquin County Encroachment Permit;and conditions and restriction of this and any <br /> 6. That permission is granted as requested,he ags to do the work described inn accordance with all terms, <br /> attached sheet,included as general or special III provisions. <br /> Signature of Applicant-Tide Date <br /> FIELD INSPECTOR COMMENTS <br /> FDRWEWAY: <br /> »»»»»»»»»»»»»»»EMSTIZNG CONDITIONS«««««««««««««««««««« <br /> None Dirt ❑ Gravel ❑ Aggregate 1� ' <br /> El Paved(poor) <br /> ❑ Paved(Good) ❑ <br /> r►?i Towards Pavernant ❑ ❑ <br /> Away from Pavement 1�'+None 1Z ESS-Type <br /> fel � ❑ Cross Drain El Size <br /> Other pipes in neighborhood: Yes El No W� <br /> Attac lament to neighbors Pte: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> 54 <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6: BARRIERS alon$Rrgbt-of-Way <br /> 7. DITCH Yes ❑ No <br /> �] If Yes: V Style ❑ 2 Poi ❑ Other E] With - <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIRE INDUSTRIAL ❑ <br /> 1. DRIVEWAY: <br /> SFTL �( COMMERCIAL EJ AGRICULTURE <br /> El <br /> PAVED with 2_ <br /> "Mia Depth A.C.over � Min.Depth 3/4"A.B. <br /> Notes <br /> Ft and Diameter of Pipe Inch <br /> 2. PIPES: Length of Pipe Rogirned: ®-- <br /> To be corrected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length. (with Proposed) Total N>mrber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes Q No <br /> "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> 4. PAVED FRONTAGE: PAVED with _.Feet Measuring Feet in length and <br /> FEES <br /> Driveway Encroachment Permit base fee......................... . <br /> $85.00 <br /> Field Inspection $100.00+0'46/ft <br /> $95.00 ❑Pavedfrnntage.................................. <br /> ❑ Driveway w/or w/o pipe............................................. <br /> ❑�,Gutter,Sidewal L......................$100.00+0.98/ft <br /> ❑ Driveway w/box Culveit................ <br /> ...............................$i . <br /> Revised 8/2000 <br /> Counter\Computer,c:\Accecs\ApPLcation for Permits\Driveway and Paved Frontage <br /> Page 2 of 2 <br />