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THE APPLICANT HERESY CERTIFIES: <br /> and that the mcitided in this application are correct to the best of his/her <br /> l. That he/she has read all the provisions of this application, glesgription <br /> knowh-dge,and <br /> 2, That he/she is the owner of the respective property,or is qualifiedto represent theowner;and <br /> 3. That he/she will assume full responsibir Ay for all liability for personal injury or dantage to property w1iich may mm out of the work described above, <br /> or which may arise out of Ws&w failure to do the work provided herein;and <br /> 4. That in the event any claim of such liabirdy is made against the County of Sou Jbagion Of any official erre loyee thereof;he shall <br /> defend,indemnify and hold them and each of than harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or arry representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encreaclmrctnt Permit;and <br /> 6. That if permission is grunted as requested,he agrees to do the work described in accordance with all tarns,conditions and restriction of this and any <br /> attached as sp III provisions. <br /> Si of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTINCY CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Name ❑ Dirt ❑ Gravel ❑ Aggregate Base Paved(pbor) ❑ <br /> Pav4Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards PavaM.A ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type /Z/ <br /> Other pipes in neighborhood: Yes K No ❑ Approaches ❑ Cross Dram ❑ Size /Z <br /> Atte inme t to neighbor's pipe: Yes N No ❑ <br /> 4. BFADWALL: Yes ❑ No <br /> 5. ASPSALT CONCRETE DACE: Yea ❑ No <br /> 6. BARRIERS along Right-o&Way <br /> 7. DITCH Yes [X No ❑ If Yes: V We 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREME TS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Pt.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yea ® No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No 5 <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Nates <br /> 3. HEADWALL Yea ® No <br /> 4. PAVED FRONTAGE: PAVED with "1vlin.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Peet 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................................_....._....595.00 ❑paved frontage._............__.....:.._....$1110.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,(hitter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Appiication for PermitsVXiveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />