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THE APPLICANT HEREBY CERTIFIES: <br /> 1, That helsha has read all the provisions of this application,and that the description in sided in thus application are cx�trect to the best of er <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. That he/she will assume full responsibility for all habilily for personal injury or damage to property which may arise mrt ofthe work described above, <br /> or which may arise out of his/#ser failure to do the work provided therein;and <br /> 4. That in the event any claim of an&liability is made against the Courtly of San Joagian or any department,official or employee thereof he shall <br /> defend,mdemmid'y 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 represents ift of the applicant in the Cm*Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Faurmc m Cflt Pecmit;and <br /> 6. That if pemhission is grained as requested,he do the work described in accordance wiith all terns,conditions and restriction of this and any <br /> attar d included <br /> Si .ture of Applic�Title J D <br /> ate <br /> gn <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»?»»»»»»»»»»»>E)M TING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt ®' Gravel ❑ Aggregate Base ❑ Paved(pow) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Fl <br /> 3. PIPES: None E -Type <br /> Other pipes in neighborhood: Yes ❑ No G? Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No 19 <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETED Yes ❑ No <br /> 6. BARRIERS along Rmgbt-c£Way <br /> 7. DITCH Yes ❑ No ❑ IfYes: V Style ,� 2 Point ❑ Other ❑ Width DePth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIItEMEYM«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGkCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> L PIPES% Langoi of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No - <br /> DRAINAGE INLET REQUIRED Yes ❑ No 0 <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee..........................$85. <br /> Field Inspection <br /> ElDriveway w/or w/o pipe.................................._..... .....$95.00 El Paved framRage.._................ ...:........$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 /> 1 <br />