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1TIE APPLICANT HEREBY CERTIFIES: <br /> 1, That he/she has mad all the provisions of this application,and flat the description included in this application are correct to the best of his/her <br /> knowhvdge;and <br /> 2, 1 hat helshe is the owner of the respective property,-or is qualified to represent the owner;and <br /> 3. That he/she will assume full rrsponsili ity for all liability for P iaj+tty or damage f4 Properly which may arise out of the work described above, <br /> or which may arise out ofhis/fiar failure to do the weak provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San Jbagion or any department,official or employee thawt he 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 the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Eta 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 sheet,included as gwaral or special 111 provisions. I �/ <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR CONMIENTS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) 19 Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ® Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes N No ❑ Approaches ❑ Cross Drain ❑ Size <br /> Attadnment to neighbor's pipe: Yes ❑ No <br /> 4. gEADWALL. Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Rigit-of Way <br /> 7. DITCH Yes ❑ No ❑ if Yes: V Style ❑ 2 Point Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR, COMMERCIAL ❑ ACiRiCULTIJRE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPES: L.emgth of Pipe Regairod: Pt.and Diameter of Pipe inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No LR <br /> DRAINAGE INLET REQUIRED Yes ❑ No P <br /> Total Length: (with proposed) Total Number of Storm Drafn inlets <br /> Notes <br /> 3. HEADWALL Yea ® 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........................... 85.0 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe............................................! ❑Paved fmntage............................_....$100.00+0.46/ft <br /> ❑Driveway w/box Culvert.................................................$155.00 ❑Cuda,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />