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IM APPLICANT HEREBY Cmmus: <br /> 4. That he/she has read all the provisions o€this app&atio%and that the dmm*ion iochided in this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is theowner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibilityfor In fiabrlityfor Qeraonai injury ox damage propertyyvchM&Y arise out ofthe wodc described above, <br /> or which may arise out ofhis&er failure to do the work provided heroin;and <br /> 4. That in the event any claim of such liability is made against the Cotnty of Sea Joaganf or any deperlment,oTScial or employee thereof he shall <br /> defend,indemnify and hold them and each of them harmless for such chain;and <br /> 5. That work shall be performed by the applicant and(or any repress tatiVe of theapplicant�m the county Right-of-Way at the above indic»ited site <br /> with a valid San Joaquin County Encroachment permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in,accordance with all terns,conditions and restriction of this and any <br /> attached sheat,included as general or special III provisions. <br /> Signature of Applicant-Tifhe Hate <br /> FIELD INSPECTOR C014IIlyNTS <br /> >>>> »»»»»»»»��»»»»»EXISTENG CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregam Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Anny&an pavement ® Towards Pavement ❑ Flat <br /> 3. PIPES: Now ❑ Exmft-Type <br /> Otherpipes in neighbmhooct Yes ❑ No Approaches ❑ Cross Drain ❑ Sias C� <br /> Attadtnemt to neigldw%pipe: Yes ❑ No <br /> 4.HEADWAId.: Yes ❑ No jo <br /> ASPIIALT CONCRETE DIIM: Yes ❑ Na <br /> 6. BARRIERS along Rigbt-orf Way <br /> 7. DITCH Yes ❑ No ®, Ifyes: V Style ❑ 2 Point ❑ Other ❑ Width <br /> Depth <br /> »»»»»»»»»»»»»»»>»»»»>PERMIT REQUIREMENTS««««««««««««««««««<—<<< <br /> I.DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mia Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> i PIPE& La*&of Pipe Required; Ft and Diameter of Pipe _ Lurch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUMED Yes ❑ No <br /> Tom Length (with proposed) Total Nuaber of Storm Drok Meg, <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min Depth A.C.over "Min.Depth 3/4"A& <br /> Measuring Fed in leeg&and _Feet in width <br /> FEES <br /> Driveway Enavachment Permit base fee............................$85.00 <br /> Feld Iron <br /> ❑Driveway w/or w/o pipe,_.. ❑Pavel <br /> ❑Drivewayw/boxCulvert� . ❑Curb,Gutta,Sidewalk.......................$100.00+0.98/8 <br /> CounterlComputer,c:\Access\Apphcabon for Permita\Ihiveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />