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THE APPLICANT HEREBY CERTIFIES: <br /> T. That he/she has read all the provisions of alis application,and that the description induded in this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective proper;; ed or is qualified#o represent the ownand <br /> 3. That helshe will assume full respansiWity for all habWq for personal injury or damage to property which may wise out of the work described above, <br /> or which may arise out of hislaw failure to do the woak provided herein;and <br /> 4. That in the event any claim of such liability is made against the Candy of San Jbaclion or any department,official or employee thereof 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 Canny Riot-of-Way at the above indicated site <br /> with a valid San Joaquin County Fmx:roachmeit Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms,conditions and restricti of this and any <br /> attached sheet,included ar III provisions. i 15 0 <br /> Y W f <br /> Signature of Applicant-Tide DMJ <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»>>EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away fiom Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ® Existing-Type <br /> Other pipes in neiglborhood Yes ❑ No f9 Approaches ❑ Crass Drain ❑ Size <br /> Agent to neighbors pipe: Yea ❑ No <br /> 4.HEADWALL: Yes ❑ No J <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS alnng Right-af Way <br /> 7. DITCH Yea ❑ No 5< Lf Yes: V Style ❑ 2 Point ❑ Odra ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑ COMMERCIAL AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPES: Length of Pipe ReTrired: Ft and Diameter of Pipe _ Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Measuring Feet 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......................................._.. .t <br /> 5.00 ❑Paved framtage..................................5100.00+0.46/R <br /> ❑Driveway w/box Culvert.............................................. 5.00 ❑Curb,Gutter,sidewalk......................$100.00+0.98/ft <br /> Counter\Computer,c:\AaesslApphcation for Pennds\Dnveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />