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THE APPLICANT HEREBY CERTIFIES: <br /> I, That he/she has read all the provisions of tl»s application, <br /> MW that the description mchl&d in this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owne,and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to prey which may arise out of the work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and official or employee thereof he shall <br /> 4. That in the event any claim of such liability is made against the County of San Joai*n or any depa tment, <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall ormed by <br /> tor any representative of the applicant in the County Right-of-Way at theabove indicated site <br /> with a valid Jo in Countyrmit;and <br /> 6. That if pe on is asrs to do the work described is acco rdancewith all terms,conditions and restriction of this and any <br /> attached as govisions. <br /> Q•zs�vco <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»>>>>>>»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Pav*Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type <br /> other pipes in neighborhood: Yes ❑ No ❑ Appva&w ❑ Cross Drain ❑ SIm <br /> Attadunent to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No ❑ <br /> & ASPHALT CONCRETE DIICE: Yes ❑ No ❑ <br /> G BARRIERS along Ri&- f Way <br /> 7. DITCH Yes El No El If Yes: V Style ❑ 2 Point El Other EJ Width <br /> h <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ . <br /> PAVED with "Mia Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Lzn s of Pipe Regaired: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No ❑ <br /> Total Length: (with Proposed) Total Nunber of Storm Dry Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over _"Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection <br /> El Driveway w/or w/o i $95.00 ❑Paved framtage..................................$100.00+0.46/ft <br /> ❑ Driveway w/box Culvert................. ....$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Page 2 of 2 Revised 8/2000 <br /> CountrtalComputer,c:\A�\Apphcation for Permits\�Dr'iveway and Paved Frontage <br />