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THE APPLICANT HEREBY CERMTES. <br /> and that the description included <br /> in this applicatim am correct to the best of his/her <br /> 1, That he/she has mad all the <br /> provisions of this application, - <br /> knowlwdM and <br /> 2. That tle lshe>s the owner of therespedive properly, <br /> or is q%alifiedto rw-Mt the owl and <br /> 3. That he/she will assume full responsibility for all *for personalisgury or damage to per,which may arise out ofthe work described above, <br /> or which may arise out of W,,&W failure to do the wait provided herein;and theaeot he shall . <br /> 4. That in the event any <br /> claim of such habikity is made against the County of Salt kagion or any depart ,official ore. yee <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> performed the beat$and/or any representative,of the applicant in the County Right-of-Way at the above indicated site <br /> 5. That work shall be pert by app <br /> with a valid San Joaquin County Encroachment Permit;and ons and restriction of this and any <br /> 6. That if pemrissio n is granted as requested,he agrees to do the work described in accordance with atl terms,o0tditi <br /> included as general or special M provisions �' O <br /> Date <br /> Signature,of Titre <br /> FIELD INSPECTOR CoMbIENTS <br /> E WTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None <br /> Dirt ❑ Gravel ❑ Aggregate Base ❑ Pan ed(pocr) ❑ Pav*Good) ❑ <br /> 2 SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Existing-Type <br /> Other pipes in fid; Yes ❑ No Approad>ea ❑ Cross Drain ❑ Sue C� <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HFADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DOM: Yes ❑ No <br /> 6. BARRIERS along Rigbt-of-WayDepth <br /> 7. DITCH Yes El No ❑ Ifyes: V Style E] 2 Point El Other El width <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQLBREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min-Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPM of Pips Rwpkv& Ft and Diameter o£Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes El No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (-M proposed) Total Number of Storm Dmfs Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No X(, <br /> "Mia Depth A C.over "Min Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with <br /> Measuring Feet in length and Feet in Width <br /> FEES <br /> Driveway Encroachment Permit base fee..................... .....$85.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.................................._........_.. <br /> ❑Paved frontage._....._._....__....._....$100.00+0.46h <br /> ❑Driveway w/box Culvert............................. <br /> ....................$155.00 ❑Curb,Ouster,Sidewalk.......................$100.00+0.98/ft <br /> cation for Permit ADrivewa and Paved F Pap 2 of 2 Revised 8/2000 <br /> Counter\Computer,cAAccess\Appli Y a <br />