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THE APPLICANT HEREBY CERTIFIES: that the description i�in this application are correct to the best of his/her <br /> 1. That he/she has read alk the prowions of this <br /> application,andknowlwdgv,and <br /> or is cgralifxed to represent the owner;and <br /> 2. That he/she is the owner of the respective property, <br /> or doge to P w�ch may arise out of the work described above, <br /> 3. That he/she will assume fill'responsi�h'for ail liabii�ity for Pawnal Y <br /> or which may arise out of his/her failure to do the work}mo the C Y ofSaSan Join or MY��ficial or employee thereof he shall <br /> 4. That in the event any claim of such liability is made against <br /> defend,ind and hold them and each of them halmlessfor such claim;and <br /> applicant <br /> in the Cody Rigbi-of-Way at the above indicated site <br /> 5. That rk shall be performed by the applimot and/or any rep�entative of the <br /> wo <br /> with a valid San Joaquin County Encroachment permit;and with all terms,conditions and restriction of this and any <br /> 6. That if permission is granted as requested,he ag'—to do the work descsibed in accordance <br /> attached sheet,included as general sl�al II Provisions. ,tf - 19 C— Date <br /> col Signature of Applicant-Tide <br /> FIELD INSPECTOR COMMENTS <br /> FgLOPITN4G-. <br /> »»»»»»»EXI TING CONDITIONS«««««<<<<<<«««««««««None ❑ Dig JKGravel ❑ ��te Base ❑ Paved(poor) ❑ paved(Good) ❑Flat <br /> Away from Pavement ❑ Towards Pavemertt ❑None ❑ E dstis>g Type /z G M ❑ Cross Drain Elsize <br /> pipes m� Yes ® No ❑ APPS <br /> A�hma.to neighbor's pipe: Yes ❑ No El <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DEU: yes ❑ No <br /> 6. BARRIERS alongRigl4-of-Way N <br /> 2 Point ❑ Other El Width Depth <br /> 7. DITCH Yes ® No EDIfyes: V sty/e 10 <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> COMMERCIAL F-1 AGRICULTURE 1-1INDUSTRIAL El <br /> "Min Depth A C.over <br /> "Min.Depth 3/4"A.B. <br /> PAVED with �_ <br /> Notes <br /> FY and Diameter of Pipe <br /> Ind -- <br /> 2. PIPES: Lavb of Pipe R-Pired: -- El No <br /> To be connected to any wcfi art driveway Pipe yes <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> ��proposed) Total Nmnber of Storm Orales Inlets _ <br /> Notes Total Length: <br /> 50 <br /> 3. HEADWALL Yes ® No <br /> "Min,Depth A.C.over "Min.Depth 3/4"AB. <br /> 4. PAVED FRONTAGE: PAVED with <br /> Measuring Feet in length and _.Feetn width <br /> FEES <br /> Driveway Encroachment Permit base fee......................... .$85.00 <br /> Field Inspection <br /> $95,00 ❑Paved frontage..................................$100.90+0.46/ft <br /> El Driveway w/or w/o pipe....................................._........ ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> ❑ Driveway wAwx Culvert............. . <br /> .............$155.00 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage <br /> Page 2 of 2 Revised 8/2000 <br />