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THE APPLICANT HEREBY CERTIFIES: <br /> 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 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 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 descrie with all terms,conditions and restriction of this and any <br /> bed in accordanc <br /> attached sheet,included as general or special M provisions. <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS<<<<<<«««««««««««««« <br /> i. DRIVEWAY: None ❑ Dirt El Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> EK <br /> 3. PIPES: None R Eistmg-Type <br /> Other pipes in neighborhood: Yes <br /> El No Approaches ❑ Cross Drain El Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No g <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6, BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V Style ❑ 2 Point ElOther ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS TS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR A <br /> COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> oII�o3a?a°. ?'X'I'44'0k' „Min Depth 3/4"A.B. <br /> PAVED with "Min Depth A.C.over <br /> Notes <br /> F <br /> 2. PIPER: Length of Pipe Required: Ft.and Diameter of Pipe Inch--- <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No L <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No <br /> " . A.C.over "Min.Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with MinD� � ---- <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................10 <br /> Field Inspection , <br /> ........................$9 •00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> [I Driveway w/or w/o pipe......................... <br /> ❑ Driveway w/box Culvert......................I....I...... <br /> ...............$155.00 El curb,Gutter,Sidewalk................,....•$100.00+0.98/ft <br /> Pae 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage g <br />