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t:;1',', `SHE AAFPLICANr HEREBY C`ERT�S: <br /> .. on are correct to the best of his/her <br /> f. That he/she has read an the provisions ofthis appy,and that the descaip4ion i du&d in this application <br /> knawlwdge;and <br /> 2, That he/she is the owner of the respective property,or is gtcalifiedto reprawd tha0wDM and <br /> 3. Thathe/she will assume full smPh3' all�far iajucy or damage to P 'vehichmsy arise out of the work described above, <br /> Of whichmay arise out of Ws&w failure to do the work provided herein;and <br /> 4. That is the event any claim of suck liability is made against the Coady of San m or any deparhneut,official employee tbereo&he shall <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> S That work shall be performed by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin Cordy Ethsroachmeffi Pernid;and <br /> 6. That ifpemhisston hs graded as requested,he agrees to do the work described inaccordance wi&all tears,moons and restriction ofthis and any <br /> attached sheet,inchhdod crr sP 111 provisions. <br /> Signature of Applicasi-Title <br /> aft <br /> FIELD INSPECTOR COMMENTS <br /> L DRIkSWAY: Now Dirt El Gravel E] Aggregate Base ❑ Pa 4P-0r) ElPaved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement Flat ❑ <br /> 3. PIPES: Now Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No §2L Approaches ❑ Cross Drain ❑ Size <br /> Ahad to neigbbor s pipe: Yes ❑ No <br /> 4.HEADWALL: Yea ❑ No <br /> S.ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS alongRigbi-o£Way <br /> 7. DITCH Yes ❑ No ®- Ifyes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»>»»>»»>»»»»»>>>»»»»»>pERMT RgQUEREWNTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRk ULTURE E] INDUSTRIAL ❑ <br /> PAVED with "hdgm Depth A.C.over "Min.Depth 3/4"A.B. <br /> NOW <br /> L PIPM Length of Pipe R-pirvd: Ft.and Diameter of Pipe inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No El <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> ToW : (with proposed) Total Number of Storm Dry Web <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC.over "Min Depth 3/4"A.B. <br /> Measuring Fed in length and Feet is width <br /> FEES <br /> Driveway Encroachment Permit base fee.................... ......$85.00 <br /> Field Inspection <br /> ❑Driveway w/orw/o pipe................._....._..... _.. $95.0 ❑Paved :Sl(10.00+0.46/ft <br /> ElDriveway w/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.....................$100.00+0.98/ft <br /> Counter\Computer,c:VWo=\AppIic:a ion for Permits\Diiveway and Paved Frontage Pago 2 of 2 Revised 8/2000 <br />