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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 of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative ofthe 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 described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,included as general or special LII provisions. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COAEVIENTS <br /> FPEPES: None <br /> »»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> I. None Dirt ❑ Gravel ❑ Aggregate Base <br /> ❑ Paved(poor) ❑ Paved(Good) <br /> Away from Pavement ❑ Towards Pavement Flat ❑ <br /> ( Existing-Type <br /> es in neighborhood: Yes ❑ No CA Approaches ❑ Cross Drain ❑ Size <br /> nt to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No 5� If Yes: V Style ❑ 2 Point <br /> ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL ® AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with _ "Min.Depth A.C.over "Min Depth 3/4"AB. <br /> Notes F__� <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 Drafit Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with _"Min_Depth A.C.over "Min Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> F3Field <br /> ay Encroachment Permit base fee...........................$85.0 <br /> spectioneway w/or w/o pipe............................................... $95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> veway w/box Culvert-................................................$1 .00 <br /> ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Pemrits\Driveway and Paved Frontage Pae 2 of 2 <br /> Page Revised 8/2000 <br />