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TELE APPLICANT HEREBY CERTIFIES: tion 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,and that the descrip <br /> knowlwdge;and <br /> 2 That he/she is the owner of the respective property,or is qualified to represent the owner,and <br /> for sone/injury or damage to Property`''hick may arise out of the work described above, <br /> 3. That he/she will assume full responsibility for all liability per <br /> or which may arise out of his/her failure to do the work provided herein;and official or employee thereof;he shall <br /> 4. That in the event any claim of such liability is made against the County <br /> un clof San aim;and agiun or any department �P Y <br /> defend indenvuf9 and hold them and each of them harmless t of-Way at the above indicated site <br /> 5. That work shall be Performed by the applicant and/or any representative of the applicant in the County gh <br /> with a valid San Joaquin County Encroachment Pemut;and <br /> 6. That if pemussion is granted as requested,he agrees to do the work described inaccordance with all tetras,conditions and restriction of flus and any <br /> attached sheet,included as general or special III provisions. <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMAIENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> None Dirt ❑ Gravel Aggregate to Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 1. DRIVEWAY: ❑ Flat JZ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ <br /> 3. PIPES: None Existing-Type El Size <br /> Other pipes in neighborhood: <br /> Yes El No � Approaches ❑ Cross Drain <br /> Attachment to neighbor's pipe: Yes [I No <br /> 4. gEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> along Ri of-Wa 1�// o+• Drv*�w �O�oYaael <br /> 6. BARRIERS g Bbt' Y ❑ 2 Point ❑ Offer' g Width dt & -- <br /> 7. DITCH Yes KI No ❑ If Yes: V Style <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br /> INDUSTRIAL El1. DRIVEWAY: SFR <br /> LR COMMERCIAL ❑ AGRICULTURE ❑ <br /> PAVED with <br /> Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Req-ired: <br /> Ft and Dissects/of Pipe _ � <br /> Yes ❑ No <br /> To be connected to any adjacent driveway pipe <br /> DRAINAGE INLET REQUIRED Yes ❑ Nc <br /> (with proposed) Total Nmnber of Storm Drain Inlets <br /> Total Length: <br /> Notes <br /> 3. HEADWALL Yes No <br /> 11 Min.Depth AC.over �_ <br /> "Min.Depth 3!4"AB. <br /> 4. PAVED FRONTAGE: PAVED with —• Feet in width <br /> Measuring ®®_Feet in length and <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$ 5 <br /> ft <br /> Field Inspection <br /> ........$95.00 ❑ Paved frontage..................................$100.00+0.46/ <br /> 00 <br /> ❑ Driveway w/or w/o pipe...................... <br /> ❑ Curb,Gutter,Sidewalk........,..••••••••••.•$100.00+0.9 <br /> ❑ Driveway w/box Culvert................................... Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Pemits\Driveway and Paved Frontage <br />