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ApPI,ICANT HEREBY t;JuxJL L��: <br /> ,;.1. That helsha has read all the provisions of flys apps,and that the desaiption included in this application are correct to the best of ' <br /> knowfwdge;and <br /> 2. That he/she is the owner of the respective properly,or is gaaU#ed to represent the owaar,and <br /> 3. That he/she will assume full reaponsMity for ill liahifaty for personal injury or damage to property which may arise out ofthe work described above, <br /> or N&ch may arise out of biMm failure to do the workpmvidedherein;and <br /> 4. That in the event any claim of melt liabilty is made against the County of San of any department,ad&cisl or employee tht be shall <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5, That work shall be performed by the applicant and/or any representative of the applicant in She County Rigbt-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is 8ranted as requested,he agrees to do the work described in.accordance with all terms,conditions and restriction oftbis and any <br /> attached sheat,includeda�general or special fit provrsrona- <br /> Signature of Applicant-Titte Date <br /> FIELD INSPECTOR CON MEMS <br /> »»»»»»»»»»»»»»»»»»»»EMIM4 CONDTIIONS«««««««««««««««««««<< <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ .Aggregate Baso ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavainaw ❑ Towards Paved ❑ Flat ❑ <br /> 3. PIPES: None ❑ EAsting-Type <br /> . Other pipes in neighborhood: Yes ❑ No ❑ Approach ❑ Cross Drain ❑ Sm <br /> Attachment to neighbor's pipe: Yee ❑ No ❑ <br /> 4.HEADWALL: Yes ❑ No ❑ <br /> ASPHALT CONCRETE DOM: Yes ❑ No ❑ <br /> 6. BARRIERS aloagRiSlst-Cf-.Way <br /> 7. DITCH Yes ❑ No ❑ IfYes: V St* E] 2 Point ❑ Other ❑ Width Deity <br /> »»»»»»»»»»»»»»»»»»»»PERMIT RFQLqREME2M«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRiCIMTURE ❑ INDUSTRIAL. ❑ <br /> PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& I-&*of Pipe R-piimd Ft send Diamater affipe Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No ❑ <br /> DRAWAM INLET REQUIRED Yes ❑ No ❑ <br /> Total Length: (with proposed) Total Number of Storm Drain Islets <br /> Notes <br /> 3. HEADWALL Yes no No 51 <br /> 4. PAVED FRONTAGE: PAVED with "Max Depth A.C.over "Mia Depth 3/4"A.& <br /> Measuring Fed in length and Fent in width <br /> FEES <br /> Driveway Encroachment Permit baso fee............................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.......................__.. _ .__._..$95.00 ❑Paved troataga.__..._._._ _.:..__..5100.00+0.46/ft <br /> ❑Drivewayw/boxCulvert............................................_...$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CounWComputer,c:VxcessVApplication for Pe mitslDriveway and Paved Frontage Pa®e 2 of 2 Revised 8/2000 <br /> 1 . <br /> I � <br />