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TIDE AppLICANP IIEREBY CERTIFIES: and that the description included in this application are correct to the best of his/her <br /> 1. That he/she has read all the provisions of this application, <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 liability for personal injury or damage to property which may arise out of the work described above, <br /> or wbich 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 of-W a at the above indicated site <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the CountyRight- Y <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrps4o do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,inclu gen ecial pr 'sions. <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR CONIlVIENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDITIONS«««««««««««««««««««« <br /> Aggregate Base EJPaved(poor) ❑ Paved(Good) ❑ <br /> 1. DRIVEWAY: None ❑ Dirt EX Gravel ❑ <br /> 2. SLOPING: Away from Pavement <br /> ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ES Existing'Type ❑ <br /> Other pipes in neighborhood: <br /> Yes F1 No k Approaches ❑ Cross Drain Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ NoI <br /> 6. BARRIERS along Right-of-Way D <br /> 7. DITCH Yes El No � If Yes: V Style ❑ 2 Point F-1 ��' ❑ Width � <br /> »»»»>»»»»>»»»»»»»»»»»PERMIT REQUIREMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br /> 1. DRIVEWAY: <br /> SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min Depth A.C.over "Min.Depth 3/4"A.S. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: <br /> Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No 5a <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ NoQ <br /> "Min-Depth A.C.over "Min.Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with -- <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.0 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe..................... <br /> ............................$95.0 ❑ Paved frontage..................................$100.00+0.46/ <br /> $155.00 <br /> ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> ❑ Driveway w/box Culvert................................................. <br /> Pa e 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage g <br />