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THE APPLICANT IFIEliEBY CERTHUS: <br /> I. That hah#tehas read all the provisions of this application,and that the description included in this application are correct to the best of his/her <br /> knowlwdK and <br /> 2. That he/she is the owner ofthe respective properly,or is qualified to represent the ovine,and <br /> 3. That helshe wM assume firll responsibility fix all liability far personal injury or damage to property which may rue out ofthe work described above, <br /> or which may arise out of his/herfailure to do the work providedhwein,and <br /> 4. That in the event any claim of such liability is made against the County of San Jaagm or any department,official or employee ttrerecC he shall <br /> defend,indemnify and hold them and each ofthem harmless for such claim and <br /> 5. That work shalt be performed by the applicant an&or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Pew and <br /> 6. That if pemvssion is granted as requested,he agrees to do the work described in accts dance with all tenns,commons and restriction of this and any <br /> attached sheet,included as general or specrjal lli visions. <br /> S ofApplicaffi-THIe <br /> ate <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS««<«««««««««««««««««< <br /> L DRIVEWAY: Nome ❑ Dist ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING- Away from Pavement ❑ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: Nome ❑ Existing-Type <br /> pipes in 1160borhood: Yes ❑ No ❑ Approaches ❑ Drain ❑ Size <br /> to neighbor's pipe: Yes ❑ No ❑ <br /> 4.HEADWALL: Yes No ❑ <br /> S. ASPHALT CONCRETE DIICE: Yes ❑ No ❑ <br /> 6. BARRIERS atongRi&-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V Style ❑ 2 Point ❑ ❑ Width Depth <br /> »»»»»»»»»»»»»»» »»»»PERMIT REQUIREMENTS «««««««««««««««««««< <br /> 1.DRIVEWAY: SFR ❑ CO CIAL ❑ A CULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Min.Depth AC.over <br /> "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& LOMA of Pipe Required: Int..and pipe Inch <br /> To be connected to any adjacent driveway Pipe ❑ No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ ❑ <br /> Tom (with proposed) T Number of Storm Draia Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No ® . <br /> 4. PAVED FRONTAGE: PAVED with Depth AC.over Depth 3/4"A.B. <br /> Measuring F length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85 0 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe............................_._........._... 5.00 ❑Paved fin Cage........... <br /> _...._........_....$100.00+�0.46h <br /> E] Driveway w/box Culvert...:........................................ ...$155.00 ElCurb,Gutter,Sidewalk.......................$100.00+0.98/R <br /> Counter\Computer,c: \Application for Permits�ivewsy and Paved Frontage Page 2 oft <br /> Revised 8/2000 <br />