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E APPLICANT HERESY CER'T'IFIES: that the description inchrded in this application are carred to the best of his/her <br /> I. That he/she has read all the provisions of thia a }ication,and <br /> knowlwdge',and <br /> the respective property,or is qualified to represent the owner and <br /> 2. That he/she is the owner of <br /> 3, That he/she will assume full respansibUity 'U fia *ury or <br /> � y personaldamage to property whrchmay arise out ofthe work described above, <br /> or which may arise out of haslher failure to do the warllc provided herein;and official or employee th"cot he ahall <br /> 4. That in the event any claim of such liability is made against the Canty of San or my <br /> defend,indemnity and hold them and each ofthem harmless for Rich claim;and <br /> 5. That work shall be performed by the applicant and/or any re�e of the applicant in the County Right of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he to do the work described in accordance with sit tennis,conditions and restriction of this and any <br /> attached included as general or special III ora. �_ f -7 <br /> �azl <br /> Date <br /> Signature of Applicant TSI- <br /> FIELD INSPECTOR CONDIENTS <br /> L DRIVEWAY: None Dirt ❑ <br /> Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None 5 Existing"Type <br /> _ ()than pipes in neighborhood: <br /> Yes ❑ No ® Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neigbboes pipe: Yes ❑ No <br /> 4. BIZADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIKE: Yea ❑ No I� <br /> 6. BARRIERS alar$Rightof-way <br /> 7. DITCH Yes ❑ No Ifyes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREIEITS««««««««««««<<<<< «« <br /> i.DRIVEWAY: SFR <br /> fK COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Notes <br /> 2.. PIPES: Length of Pipe Regairod: Ft.and Diameter of Pipe Inch --- <br /> To be connected to any adjacent driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No 1 <br /> Total - (with proposed) Tota!Number of Storm Drada Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes R 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...........................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.............................. <br /> .$95.00 ❑Paved frontage................._......:........$100.00+0.46/ft <br /> Curb,Gutter,Sidewalk......................$100.00+0.98/R <br /> El Driveway w/box C ulvert.................................................$155.00 ❑ <br /> Pap 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage <br />