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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has mad all the provisions of this application,and that the description inchxied in this <br /> application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That He/she is the owner of the respective properly,or is gwMed to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for personal injury orto <br /> �ge ICY whichmay arise out oflhe work described above, <br /> or which may arise out of his/her failure to do the work provided hervin;and <br /> 4. That in the event any claim of such liability is made against the County of San Jba n of any department,official or employee thereof,he shall <br /> defend,indemnify and hold them and each ofthem harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the <br /> applicant is the County Rift-of-Way at the above indicated site <br /> with a valid San Joaquin County En=achauxt permit;and <br /> 6. That if pemriss on is granted as requested,lieto do the wart described in accordance with all <br /> �� heirs,conditions and restriction of this and any <br /> attache inc ded as III visions. <br /> Smgnatrae of Tithe Dste <br /> MELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>»»»»»»»>EXIST NCY CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nome ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(G.A) ®. <br /> 2. SLOPING: Away from Pavement ❑ Towar+ds Pavemem ❑ Flat LY <br /> 3. PIPES: Now ❑ Existing-Type /S "9( <br /> Other pipes in neighborhood:- Yes R1 No ❑ Approaches ❑ Cross Drama ❑ Size <br /> Attaclanent to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DUM. Yes ❑ No <br /> 6. BARRIERS along Right--c£Way <br /> 7. DITCH Yes ❑ No ❑ If yes: V We [R 2 Point ❑ other ❑ Wim Depth <br /> »»»»>»»»»»»»»»»»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR: COMMERCIAL ❑ AGRtCULnW ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth AC,over "Min.Depth 3/4"AB. <br /> Nous <br /> L PIPE& Length of Pipe Regairock Ft and Diamoter ofPipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No [� <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proper) Total Numberr of Storni Dram Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee......................... .$85.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe........................................... ..$95.0 ❑Paved fronts ..$100.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\D nveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> 1 <br /> j � <br />