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THE APPLICANT HEREBY CERTHUS: <br /> I. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of his/her <br /> knowhNdge;and <br /> 2. That he/she is the owner ofthe respective property,or is qualified to represent the owner,and <br /> 3. That he/she will assume M responsibility for all liability for personal injuryor damage to property which may arise out of the work described above, <br /> or which may arise out of hm%w 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 Joagwn or any deparbnent,official or employee thereo> he shall <br /> defend,indemnify and hold them and each of them harmless for such clams and <br /> 5. That work shall be performed b applicant and/or any representative of the applicant in the County Rift-0f-Way at the above indicated site <br /> with a valid San Joaquin Co oachment Permit;and <br /> 6. That if permission is granted he agrees to work described in accordance with all temrs,conditions and restriction of this and any <br /> attached sheet,incl �ecial III pro ons., <br /> 7 <br /> Signatureof -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»>>EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: 06h. None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None [A Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No 9 Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S ASPHALT CONCRETE DIIKE: Yes ❑ No <br /> 6. BARRIERS slang Right-of-Way U <br /> 7. DITCH Yes ® No ❑ IfYes: V Style ❑ 2 Pov t ❑ Other ❑ Width &,,e. Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR M COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Required: Ft-and Diameter of Pipe Inch <br /> To be connected to any adjacart driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No J' <br /> Total Length: (with proposed) Total Number of Storm Dry Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in lerglh and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee........................ ..$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe...........................................L $95M ❑Paved frar tag........._._....................$100.00+0.46/ft <br /> ❑ Driveway w/box Culvert.................................................$155.00 ❑curb,Gutter,Sidewalk_......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> 67. <br /> f 4,C-e Oc-C. P Zjt <br />