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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 included in this application are correct 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 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 them harmless for such claim;and <br /> 5. That work shall be performed b the p'cant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin achment Permit;and <br /> 6. That if permission is ed uest , e agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,' d_ed en or special III provisions. <br /> Signature of Applicant-Title <br /> ate <br /> FIELD INSPECTOR CONE%IENTS <br /> »»»»»»»»»»>>>>»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None 9, Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ® Flat ❑ <br /> 3. PIPES: None K Existing-Type <br /> Other pipes in neighborhood: Yes .& No ❑ Approaches ❑ Cross Drain ❑ Size !r <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No 1_I^. <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS alongRigbt-of-Way <br /> 7. DITCH Yes 9 No ❑ If-Yes: V Style 2 Point ❑ Other ❑ Width Depth <br /> »»»»>»»»»»»»»»»»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR CR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Notes <br /> 2. PIPES: 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 <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with 2 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. <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.............................................. .$95.00 <br /> ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/box Culvert................................................$155.00 ❑ Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> CounterlComputer,c:\AccesslApplication for PermitslDriveway and Paved Frontage Page 2 of 2 <br /> Revised 8/2000 <br />