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THE APPLICANT HEREBY CERTIFIES: <br /> 1 That he/she has read all the provisions of this application,and that the <br /> 'descrkkouincluded 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 property,oris quaHfi to represseat the owner;and <br /> 3. That he/she will assume full responsibilityfar al!liab7ify for personal inyray or damage property whichmay arise out of the work described above, <br /> or which may arise out of Ws/ha failure to do the work pmvidedhaein;and <br /> 4. That m the event any claim of such liability is made against the County of San Jbagiun or 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 an&cf any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Eua+ ohnaaot Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all <br /> attached included as ori conditions and restriction of this and any <br /> spacial III prpa�. <br /> ol <br /> Signature of Appiicaat-Titre <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base <br /> ❑ P- r) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away&om Pavemart ❑ Towards Pavame't ❑ Flat E <br /> 3. PIPES: None ❑ Existing-Type See /b Le, <br /> Other Pipes in nei&mhoock Yes ❑ No ® Approaches ❑ Cross Drain ❑ Size U <br /> Attachment to neighbor's pipe: Yes ❑ No �]( <br /> 4. HEADWALL: Yes ❑ No B <br /> S ASPHALT CONCRETE DEM: Yes ❑ No <br /> 6 BARRIERS along Rigirt-d.Way <br /> 7. DITCH Yes ❑ No If Yes: V e <br /> � ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT RE <br /> QLRREMENTS«««««««««««««««««««« <br /> I.DRIVEWAY: SFR [ COMMERCIAL ❑ AGRf'ULTURE <br /> El INDUSTRIAL El <br /> PAVED with "Min.Depth AC.over "Min.Depth 3/4".k& <br /> Notes <br /> 25XrS .e`3 ! <br /> 41 9Yiwno( y1o� Sevu,y�5 xa Ur uSe, Ct.+-, <br /> No• vP��, �s h«a,ell, <br /> L PIPES: Length of Pipe Required Ft.and Diameter of Pipe _ Inch <br /> Tobe connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length. (with proposed) Total Naaaber of Storm Drain Inlets <br /> Notes E::: <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with 11 Mia Depth A.C.over <br /> "Min.Depth 3/4"A.B. <br /> Measuring Fed in length and Feat in width <br /> FEES <br /> Driveway Encroachment Permit base fee..................... <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe........................._........... ........$95.90 ❑Paved fronts <br /> gra ...........................$190.00+0.46/ft <br /> Driveway w/box Culvert.................................................$155.00 <br /> ❑Curb,Gutta,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\AMlication for Pamits\Driveway and Paved Frontage Page 2 of 2 <br /> Revised 8/2000 <br />