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E APPLICANT HEREBY CERTIFIES: <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 /> knowh*e;and <br /> 2, That he/she is the owner of the respective propeciy,or is gaalified to represent the owner;and <br /> 3. That he/she will saw=full responsibility for all liability for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of hMier failure to do the wodcprovidedherein;and <br /> 4. That in the event any claim of such liability is made against the County of San Joagiun or any department,official or employee thaeol;he shall <br /> defend,indemnify and hold them and Beach of them harmless for such claun;and <br /> 5. That work shall be performed by applicant and/or any representative of the applicant in tare County Right-of-Way at the above indicated site <br /> with a valid San A croachnient Permit;and <br /> 6. That if pennissi erred,he agrees to do the work described in accordance with all terns,conditions and rostridion this and any <br /> attaches sheet special.III provisions. <br /> S' App Titla Daw <br /> FIELD INSPECTOR COMMENTS <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel g Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 3. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type J 2,"9( <br /> Other pipes in neW"rhood: Yes 15a No ❑ Approaches ❑ Cross Drain ❑ Stu F /2! it <br /> Attachment to neighbors pipe: Yoe ❑ No l"0 <br /> 4.HEADWALL: Yea ❑ No <br /> S.ASPHALT CONCRETE DUM: Yes ❑ No <br /> 6. BARRIERS along Rigbt-of-Way <br /> 7. DITCH Yes ❑ No ❑ IfYes: V Style 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUMEM DM«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR. COMMERCIAL ❑ AGRk'ULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "11,im.Depth A.C.over "Min Depth 3/4"A.B. <br /> Notes <br /> L PIPES: Length of Pipe Required: Ft and Diameter of Pipe _ Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Fed in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee..................... .....$85. <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe..................................._._ ..$95.0 ❑Paved&Maga_ .. _....$100.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Aaess\Application for PermitsUhiveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />