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E APPLICANT HEREBY CERTIFIES: <br /> 1. Thai he/she has read all the provisions <br /> of this ap hellion,and that the On in d inthis application are correct to the best ofhis/her <br /> knowhvdge,and <br /> he/she is the owner of the respective property,or is qualified to r the owner;and <br /> 2. That h arise out of the work described above, <br /> 3. That he/she will assnms full responsibr7itY <br /> for aii tidy for personal mJm'9 or damage t4 propertyvvhtchmxy <br /> or whichmay arise out of his/her failure to do the wodL provided herein;and Official of employee thereof;he shall <br /> 4. Tbat in the event any claim of such liability is made against the County of San Jbagiuz4 or any depmti , <br /> defend,m&mify and hold them and each of them harmless for such claun,and -of-Wa at the above indicated site <br /> 5. That work shall be performed by the applicant and/or any re�of aPP in the County Right Y <br /> with a valid San Joaquin County End Pant;and �s and restriction of this and any <br /> 6. That if percussion.is granted as requested,he agrees to do the work deco ibed in accardanoe vA&all teens, <br /> dyed inolu as or special III Provisions- <br /> Date <br /> Date <br /> Signature of Applicuit <br /> FIELD INSPECTOR CONIlMdENTS <br /> »»»»»»»»»»»»»»»»»»»»MasTING CONDITIONS«««««««««««««««««««« <br /> Dirt F-1Gravel ❑ Aggregate Base ® Pmved(poar) ElPaved(Good) ElFLDFJVEWAY: Node ❑ FlatOPING: Away$ons PavemaA ❑ Towards Pavement3. PIPES: Nacre ® Existing-TYPIC r <br /> Other pipes in neigjiborliood: Yes ❑ No . ❑ Approaches ❑ Crow Drain ❑ Size I (DY] <br /> Attacbmeent to ne4mbor's Pore; Yes ElNo ® ,n 2 m�" J <br /> 4. BEADWALL: Yea ❑ No <br /> S. ASPHALT CONCRETE DUM: Yes ❑ No <br /> 6. BARRIERS abng Itight-0£way <br /> 7. DITCH <br /> Depth <br /> Yea ❑ No 4g Ifyes: V Style E] 2 Point ElOthsr ❑ width <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS<<<<<<«««««««««««««« <br /> 1.DRIVEWAY: SFR [3. COMMERCIAL ❑ AGRWULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPM Length of Pipe Repaired: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yen ❑ No Q <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (wM proposed) Total Number of Storm Drain Islets <br /> Notes <br /> 3. HEADWALL Yea no No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Wm Depth A.C.over "Min.Depth 3/4"A.B. <br /> Mei Feet in length and Feetin width <br /> FEES <br /> Driveway Encroachment Permit base fee......................... . 85.00 <br /> Field Inspection <br /> ._..........._.__ $95.00 ❑Paved frontage------------- .._----$ <br /> 100.00+0.46/ft <br /> El Driveway w/or w/o pipe............._..........El Driveway w/boxcalvert........................................ <br /> .........$155.00 El curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Apphcation for PermilADriveway and Paved Fromm <br /> Page 2 of 2 Revised 8/2000 <br />