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THE APPLICANT HEREBY f this application,and that the description included in this application are correct to the best of bis/her <br /> 1. That he/she has P1O <br /> knowlwdge;and represent the owner,and <br /> 2. That he/she is the owner of the respective property,or qualified to jury <br /> assume full responsibility for all liability for personal injury <br /> or damage to pr°P�3'which may arise out of the work described above, <br /> 3: That he/she will provided herein and <br /> or which may arise out of his/her failure to do the work pr of son Joagiun or any department,official or employee thereof he shall <br /> 4. That in the event any claim of such liability <br /> is made against the County <br /> defend,indemnify and hold them and each of them harmless for such claim;and applicant m the County Rightof Way at the above indicated site <br /> 5. That work shall be Performed by the applicant and/or any representative of the app <br /> with a valid San Joaquin County Encroachment Permit;and conditions and restriction of this and any <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms, <br /> attached t included as general spec at pro ' ions. zo, <br /> /Pvzj- <br /> ;ct&t Date <br /> Si of Applicant-Tide <br /> FIELD INSPECTOR CoMN[ENT5 <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDMONS<<<<< «««««««««««««« <br /> None ❑ Dirt ❑ Gravel X Aggregate Base <br /> ❑ Paved(poor) ❑ Paued(Good) ❑ <br /> 1. DRIVEWAY: � Flat ❑ <br /> 2. SLOPING: <br /> Away from Pavement ❑ Towards Pavement <br /> 3. PIPES: None ® E>dstin�-Type ❑ Size l� <br /> ❑ ❑ <br /> Other pipes in nreighborhood: Yes No Approaches Cross Drain <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS al°ngRiglnt-°f-Ways ❑ Width Depth7. DITCH Yes ❑ No ® If Yes: V Style ❑ 2 Point ❑ <br /> ««««««««««««««««««« <br /> PERIRQ�gEMENTS« <br /> »»»»»»»»»»»»»»»»»»» <br /> AGRICULTURE ❑ INDUSTRIAL El1. DRIVEWAY: SFR [I COMMERCIAL <br /> Min.Depth.A.C.over "Min Depth 3/4"A B. <br /> PAVED with —"""– <br /> Notes <br /> Length of Pipe Required: Ft.and Diameter of Pipe -- --- <br /> 2. PIPES Yes El No <br /> To be connected to any adjacent driveway pipe <br /> DRAINAGE INLET REQUIRED Yes <br /> ❑ No <br /> (with proper) Total Number of Storm Drain Inlets — <br /> Total Length: ,___________. <br /> Notes <br /> 3. HEADWALL yes Q No , Min.Depth 3/4"A.B. <br /> PAVED with "Min.Depth A.C.over <br /> 4. PAVED FRONTAGE: —' Feet in width <br /> Measuring Feet in length and —__„_ <br /> FEES <br /> Driveway Encroachment Permit base fee..................... . <br /> ....$85.00 <br /> Field Inspection $95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/or w/o pipe.......................I................... <br /> ..$155.00 El Curb,Gutter,Sidewalk......................$100.00+0.98/ <br /> ft <br /> ❑Driveway w/box Culvert,................................. .. Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Aceess\Application for Permits\Driveway and Paved Frontage <br />