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APPLICANT HEREBY CERTHIES: <br /> That he/she has read all the provisions;of this application,and that the descxiptiasr included it this application are correct to the best ofhis/her <br /> knowhvdge:and <br /> That he/she is the owner ofthe respective prig, is quahified#o rrdareseat the owned and <br /> 3. Thai he/she will assume full responsiMityf+or all liability for personal injury ordamw to property which may arise out of the wodc described above, <br /> or whichmay arise out of h6tw failureto do the wodcprovided h<erein;and <br /> 4. That in the event any claim of such liability de is maagainst the County of San hragion or any department,of So&I or employee them he shall <br /> defend,indemnify and hold them and each ofthem harmless for such claim;and <br /> 5. That work shall be performed by this applicant and/or any represemtatift of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachmait Pefflig and <br /> 6. 'That if permission is granted as requested,he ag nes to do the work described in accordance with all terns,conditions and restriction of tbis and any <br /> attached sheat,included as general or spemal M provisions. <br /> Signaime of AppHca ii-Title Date <br /> FIELD INSPECTOR C:014IMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRItIEWAY: None ❑ Birt Gravel ❑ AMegate Base ❑ Paved(poor) ❑ Pav(Good) ❑ <br /> 2. SLOPING: Awayfrom Pavement ® Towards Pavemar>t ❑ Flat ❑ <br /> 3. PIPES: Now ❑ Existing-Type /Z'10 C R P <br /> Other pipes in neighborhood: Yes No ❑ Approaches ❑ Cross Drain ❑ Size <br /> Attar to neighbor's pipe: Yes ❑ No <br /> 4.HEADWALL: Ya. ❑ No <br /> 5, Acnrrer.T CONCRETE D=. Yes ❑ No <br /> 6. BARRIERS alonig} <br /> g R >tof-Way <br /> 7. DITCH Yea ❑ No ❑ IfYes: V Style 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> E. PIPES: Lcogth of Pipe R"Ficod: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacart driveway pip. Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: (with proposed) Total Number of Storm Draft Inlda <br /> Notes <br /> 3. <br /> HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Fed in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee....................... ...585.00 <br /> Feld Inspection <br /> ❑ Driveway w/or w/o pipe................. .... _... _.. _..$95.00 ❑Paved fimtage_...................$100.00+0.46/ft <br /> ❑Driveway w/box Culvert..........................................._....$155.00 ❑Curb,Gutter,Sidewalk.....................$100.00+0.98/ft <br /> Counter\Computer,cAAccess\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> i , <br />