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�'- TIRE APPLICAM HEREBY CERTIFIES. that the ink in this application are correct to the best of his/her <br /> andf. That he/she has read all the provers ofthis app#iimtion, <br /> knowlwdge;and <br /> e or is qual fialto the owns,and <br /> 2. That he/she is the owner of the respediv propert3; whie�r may arise out of the work described above, <br /> 3. That he/she will assume full respons"'ty far <br /> all,liability for personal inj+uY a t0 ply <br /> a which may arise out of hislhx failure to do the work provided herein;and ee thereat he shall <br /> 4. That is the event any <br /> claim of such liabikity is made against the Couaty of San Joao*a of any dep > of employ <br /> defend,indemnify and hold them and each of them haFmlesa for such claim;and �f <br /> 5. That work -Way at the above indicated site <br /> be performed by the applicant anshall d/or any represemb*'re of the applicant in the County Right y <br /> with a valid San Joaquin County EncroachmentPerrifi and <br /> 6. That if permission is granted as requested,he agreea to do the work described in accordance with all tens,conditions and restriction of this and any <br /> attached sheet included cu special lII ons. �� <br /> 115) <br /> Date <br /> Signature of Applicaut-Title <br /> FLELD INSPECTOR COMMENTS <br /> »»�»»»»»»»»»�»»�»»»»»>EXISTING CONDPniONS<<<<< «««««««««««««« <br /> Dirt ❑ Gravel ❑ Awe Base Pav4vor) ElPaved(Good) ❑ <br /> 1. DRIVEWAY: None ❑ . <br /> 2 SLOPING: Away k m Pavement El To,uw&Pavemt-t ElFlat <br /> 3. PIPES: None Existing-Tyles Sm <br /> Other.pipes in Ood: Yes El No Approaches Cross Drain ❑ <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HF,ADWALL: Yea ❑ No <br /> 5. ASPHALT CONCRETE DM: Yes ❑ No <br /> 6. HARRIERS al-*Ri&-of-Way <br /> 7. BITCH <br /> Yes EJ No ® If Yea: V Style ❑ 2 Point ElOther F-1 Width Depth <br /> MENTS«««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIRE <br /> 1.DRIVEWAY: SFR E9 COMMERCIAL -E-1 AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> L PIPE& Length of Pipe Rwpirod Ft.and Dimader of Pipe _ Incia <br /> To be connected to any adjacent driveway Pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total : (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes ® No X <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Min.Depth A.C.over "Min.Depth 314"A.B. <br /> Measuring Feet in length and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85.00 <br /> Field Inspection ❑pavedfi�amtage............_..._........._..._$100.00+0.46/ft <br /> El Driveway w/or w/o pipe:......................I......................... <br /> $95.00 <br /> ......................$155.00 El curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> El Driveway w/box Culvert.......................... <br /> Page,2 of 2 Revised 8/2000 <br /> Cou ter\Computer,6,Access\Applicatiom for Permits\Driveway and Paved Frcmtage <br />