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THE APPLICANT HEREBY CERTIFIES: <br /> I. TlW he/she has read all the provisions of this a <br /> knowlwdge;and pplication,and that the description included in this application are correct to the best of his/her <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 h for <br /> or which may arise out of ability Personal injury or damage to property which may arise out of the work described above, <br /> Y 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 an <br /> defend,indemnifyharmless for such claim;and <br /> and hold them and each of them Y department official or employee thereof;he shall <br /> 5. That work shall be performed by the applicant and any representative o€the applicant in the County Right of--Way at the above indicated site <br /> with a v Joaquin County Encroachment Permit;and <br /> 6• Tit• renis ion is granted as reu <br /> a q he agrees to do the work described in accordance with all terms,conditions and restriction ofthis and any <br /> >;included n or spec III ovisions. <br /> Signature of pli -Title�/ V <br /> Date <br /> »»»»»»»»»»»»»»»»»»FIELD INSPECTOR COMMENTS <br /> EXISrAggregateBase <br /> ONDITIONS«««««««««««««««««««« <br /> i. DRIVEWAY; None ❑ Dirt <br /> vel <br /> 2. SLOPING: Away from Pavement ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Exi <br /> -Type (2� <br /> Other pipes in neighborhood If <br /> No ❑ <br /> Yes Approaches El Cross Drain <br /> Attachment to neighbors pi . No ❑ Size �� <br /> YesYes ❑ <br /> 4. HEADWALL: pip <br /> ❑ No <br /> 5. ASPHALT CONCRETE DIKE: <br /> Yes ❑ No <br /> 6. BARRIERS along Right-of-W <br /> 7. DITCH Yeso ❑ If Yes: <br /> Style ❑ 2 Poirrt ❑ Other ❑ Width <br /> »»»»»»»»»»»»»»»»»»»» ----- Depth <br /> PERMIT <br /> 1. DRIVEWAY: SFR �MENTS«««««««««««««««««««« <br /> ❑ COMMERCIAL, AGRICULTURE <br /> PAVED with El INDUSTRIAL El_____°Min.Depth A.C.over <br /> Notes -._.,_..,__„Min-Depth 3/4”A.B. <br /> 2. PIPES: Length of Pipe Required: .,_________Ft.and Diameter of pipe Inch <br /> To be connected to any adjacent driveway - <br /> pipe Yes ❑ No ❑ ---__ <br /> DRAINAGE INLET REQUIRED Yes <br /> ❑ No ❑ <br /> Total Length: <br /> Notes .__________1(with proposed) Total Number of Storm Drain Inlets <br /> 3. HEADWALL Yes <br /> [] No <br /> 4• PAVED FRONTAGE: PAVED with <br /> -- a Min_Depth AC.over �_„Min.Depth 3/4"A.B. <br /> Measuring Feet in len <br /> gth and in width <br /> Drivay Encroachment Permit base fee....................... ...$85.00 FEES <br /> Fi d Inspection <br /> Driveway w/or w/o pipe............ <br /> $ 5 00 <br /> El Driveway w/box Culvert........................................... ❑ Paved frontage................. $100.00+ <br /> . <br /> 5.00 0.46/ft <br /> ❑ Curb,Gutter,Sidewallc...,.,..,.„•••.•,••. <br /> CounterlComputer,c:lAccess ••$100.00+0.98/ft <br /> Application for PermitslDriveway and Paved Frontage <br /> Page 2 of 2 <br /> Revised 8/2000 <br />