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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 includedin this application are coned to the best of his/her <br /> knowlwdge;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 lia for <br /> or which may arise out of his/her failure to do the wobrk provided hePersonreinJandore to Property which may arise out of the work described above, <br /> 4. That in the event any claim of such liability is made against the County of San Joaqiun or any deparhneat,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 m 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 agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attac sheetinclu as general or special pro Drys. <br /> Signa I <br /> o licant-Titl <br /> ate <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>EXISTING <br /> INSPECTOR COAMONTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> I. DRIVEWAY: <br /> None JR Dirt ❑ Gravel ❑ Aggregate Base <br /> 2. SLOPING: y. Awa &otn Pavement El Towards ❑ Paved(poor) ❑ Paved(Good) <br /> ❑ Existing-Type Pavement ❑ <br /> 3. PIPES: None ❑ Flat <br /> Other pipes in neighborhood: Yes No ❑ <br /> Attachment to neighbor's pipe: Approaches EJ Cross Drain ❑ Size <br /> 4. HEADWALL: Yes ❑ No <br /> I'es ❑ No 0 <br /> 5. ASPHALT CONCRETE DIKE: <br /> Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ® No <br /> ❑ If Yes: V Style ® 2 Point <br /> ❑ Other, ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT <br /> I. DRIVEWAY; QREMENTS«««««««««««««««««««« <br /> SFR COMMERCIAF, ❑ AGRICULTURE <br /> ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over <br /> Notes Min.Depth 3/4"AB. <br /> 2. PIPES.. Length of Pipe Required: —_Ft.and Diameter of pipe <br /> To be connected to any adjInch <br /> _acent driveway pipe Yes ❑ No —�— <br /> DRAINAGE INLET REQUIRED Yes <br /> ❑ No <br /> Total Length: """ Proposed)(with ro osed <br /> Notes '-"---•--- ) Total Number of Storm Drain Inlets <br /> 3. HEADWALL Yes EE No <br /> 4. PAVED FRONTAGE: PAVED with <br /> -- _'Mm "A.B. <br /> .Depth AC.over Min.Depth 3/4 <br /> Measuring � Feet in length and <br /> —� Feet in width <br /> Driveway Encroachment Permit base fee................. ES <br /> Field $85.00 �( Z <br /> Inspection <br /> ❑Driveway w/or w/o pipe................................................$95.00 <br /> EJDriveway w/box Culvert........I...................".....��•��••���"" ❑Paved frontage........................ $100.00+0.46/8 <br /> .......... <br /> """ Curb,Gutter,Sidewallc.............""•"•,•,••$100.00+0.98/8 <br /> CounterlComputer,c:lAccess\Application for permitslDriveway and Paved Frontage Pae 2 of 2 <br /> Page Revised 8/2000 <br />