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1HE AppLICANT HEREBY CERTIFIES: application are correct to the best of his/her <br /> 1. That he/she has read all the provisions of this applicattOn,ettd that the description included m thts <br /> knowlwdgz,and <br /> 2. That he/she is the owner of the respective properly,or is qualified to represent the owner,and arise out of the work described above, <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to property which may <br /> or which may arise out of his/her failure to do the work provided herein and is official or employee thereof he shall <br /> 4. That in the event any claim of such liability is made against the County of San Joagmn or any department <br /> defend,indemnify and hold them and each of them harmless for such claire;and t of-Wa 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 Righ- Y <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if percussion is granted as requested,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attar d sh et inclu as general or spec' provisions. �) 0 0 <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EMSTING CONDITIONS«««««««««««««««««««« <br /> Gravel Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ElG <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Flat El2. SLOPING: Away from Pavement Towards Pavement ❑ <br /> 3. PIPES: None ❑ Existing-Type ❑ <br /> Other pipes in neighborhood: Yes ❑ No El Drain Sita <br /> Approaches <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. ByADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Rigbt-of-Way <br /> 7. DITCH Yes El No If Yes: V Style ❑ <br /> 6L2 Poirrt ❑ Other El Width Depth — <br /> »»>>>>>>,»»»»»»»»»»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: <br /> SFR COMMERCIAL ❑ AGRfCULTURE ElINDUSTRIAL El <br /> with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> — <br /> 2. PIPES: Length of Pipe Required: Ft.and Diaa►eter of Pipe �-- Inch <br /> Tobe connected to any adjacent driveway pipe <br /> Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: �^ <br /> (with proposed) Total Number of Storm Drain Inlets — <br /> Notes <br /> 3. HEADWALL Yes E0 NO Mia Depth A.C.over Min.Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with _ <br /> " <br /> Feet in length and Feet in width <br /> Measuring _—. <br /> FEES <br /> Driveway Encroachment Permit base fee...................... <br /> $55.0 <br /> Field Inspection <br /> ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/or w/o pipe.............................................. .$95.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> El Driveway w/box Culvert................................................$155.00 <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage <br /> Page 2 of 2 Revised 8/2000 <br />