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APPLICANT HEREBY CERTIFIES: <br /> end that the description included in this application are correct to the best of his/her <br /> That hedshe has read all the provivions of this application, <br /> knowlvedge;and <br /> 2. That he/she is the owner of the respective Property,or is qualified to represent the ovvnen and <br /> 3. That he/she will assume full responsibility <br /> for all liability for Porsonni injury or damage to property which may arise out ofthe work described above, <br /> or which may arise out ofh6ter failure to do the work provided herein;and thereot he shall <br /> 4. That in the evebt any claim of such liability <br /> is made against the County of San Jaacpnn or any department,official or employee <br /> defend,indemnify and hold them and each of them harmless for such Claim;and <br /> 5. That work shall be perfm-d by the applicant and/or-Y representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is @canted as requested,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sleet,' ded as general or speeial IDI provisions. <br /> Date <br /> Signatum of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> EMTEgG COND]MONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Norse Dirt ❑ Gravel ❑ .Aggregate Base ElP*ved(Ponr) ❑ Paved(Good) El <br /> 2. SCOPING: Away f am Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Now ® Existing-Type <br /> Other s in d; Yes No ® Approaches El Cross <br /> Drain ❑ Size <br /> pipes El <br /> Attachment to neighbor's pipe: Yea ❑ No <br /> 4. HEADWALL: Yes ❑ No IN <br /> 5. ASPHALT CONCRETE DOM: Yes G No ❑ <br /> 6. BARRIERS along Rigb-of Way <br /> 7. DITCH yes ❑ No Ifyes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUMEMDM«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL. ❑ AC3RtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPM L-411 of pipe Required: Ft and Diameter of Pipe hkch <br /> To be connected to any adjacent driveway pipe yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No R <br /> Total Length: (with Proposed) Total Number of Storm Drsk Inlets <br /> Notes <br /> 3. HEADWALL yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee.................... ......$85.00 <br /> Field Inspection <br /> ElDrivewa w/or w/o i $95.04 F] Paved fiomtage•..._........... __.:.._....5100.00+0.46/R <br /> ❑Driveway w/box Culvert.................................................$155.00 ❑Curti,Gutter,Sidewalk.......................$100.00+0.98/R <br /> Counter\Computer,c:\Acc=\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> t <br />