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THE AppLICANT IIEREBY 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 /> knowlwdge.,,and <br /> 2. Tbat 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 Joagiun 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 is a he agrees to do the work described in accordance with all terms,conditions and reshictio of this and any <br /> attached mclu g ecial III provisions. <br /> y D <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> ❑ <br /> i. DRIVEWAY: None ❑ Dirt ❑ Gravel F-1 Aggregate ❑Base Paved(poor) Paved(Good) <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type (2,t'dj <br /> Other pipes in neighborhood:' Yes ® No ❑ Approaches ElCross Drain El Size �f�__❑ <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No 19 <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS alOngRigbt-of-Way <br /> 7. DITCH Yes ® No El If Yes: V Style 9 2 Point ❑ Other [:] Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> �y COMMERCIAL El AGRICULTURE El INDUSTRIAL <br /> ❑ <br /> U�t <br /> PAVED with "Min Depth A.C.over "Min Depth 3/4"A.B. <br /> Notes <br /> Pe Rte' <br /> 2. PIPES: Length of Pi Bred: Fx.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No fK <br /> Total Length: (with proposed) Total Nmnber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "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 /> [I Driveway w/or w/o pipe.............................................. ❑ Paved froutage..................................$100.00+0.46/ft <br /> El Driveway w/box Culvert........................................... <br /> $155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Pa 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page <br />