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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of his/her <br /> knowtwdge;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 liability for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San Joaqiun 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 County Rigbt-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is grantedd,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet, l /'4 <br /> III provisions. <br /> x c x ! — Zfo c7 <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ® Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement [ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None 9 Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attacbment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No 91 <br /> 6. BARRIERS along Riglt-of-Way <br /> 7. DITCH Yes ❑ No Z If Yes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL k AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No B <br /> DRAINAGE INLET REQUIRED Yes ❑ No R <br /> Total Length: (with proposed) Total Number of Storm Drams Inlets <br /> Notes <br /> 3. HEADWALL Yes 0 No <br /> 4. PAVED FRONTAGE: PAVED with "Minn.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 /> ❑Driveway w/or w/o pipe................................................$95.00 - ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/boxCulvert................................................$155.00 ❑ Curb,Cutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />