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THE APPLICANT HEREBY CERTHUS: <br /> 1• That he/she has read all the provisions of this applicauM <br /> lmowtwdge,and and that the description mctuded m 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 ail liability for personal injury or damage to property which may arise out of <br /> or which may arise out of his/her failure to do the work provided herein;and the work described above, <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 of the applicant m 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 requestyd,he agrees to do the work described in accordance with all terms conditions and restriction of this and any <br /> attached shee included as general especial III provisions. <br /> Signature of Applicant-Title <br /> Date <br /> FIELD INSPECTOR C014MMNTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> I. DRIVEWAY: ❑ <br /> Away <br /> ❑ Dirt Gravel ❑ Aggregate Base ❑ ) <br /> Z. SLOPING: r ElPaved(Good) <br /> way from pavement Paved(poo f 7J Towards Pavement ❑ Flat <br /> 3. PIPES: None Existing-Type ❑ <br /> Other pipes in neighborhood. Yes ❑ No ❑ <br /> Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ Na (� <br /> 6. BARRIERS along Rigbt-of-Way <br /> 7. DITCH Yes ❑ No XL If Yes: V <br /> Style ❑ 2 Paint ❑ Other ❑ Width DeA <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL <br /> ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth AC.over <br /> Notes —�_ Mm.Depth 3/4"A.B. <br /> 2. PIPES: Length of Pipeired: <br /> Requ _.Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> j"� <br /> (�j( —�— <br /> DRAINAGE INLET REQUIRED Yes ❑ No 9 <br /> Total Length: (with proposed <br /> Notes `— ) Total Number of Storm Dram Inlets <br /> 3. HEADWALL Yes 0 No <br /> 4. PAVED FRONTAGE: PAVED with <br /> ________"Mm-Depth A.C.over Mitt Depth 3/4"AB. <br /> Measuring Feet in length and <br /> Feet in width <br /> FDrniveway Encroachment Permit base fee............................$85.00 FEES <br /> spectioneway w/or w/o pipe.................................................$95.00 ❑ Paved frontage................................ $100.00+0.46/ft <br /> ewayw/boxCulvert................................................$155.00 ❑ Cub,Gutter,Sidewalk......................$100.00+0.98/ft <br /> Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Pae 2 of 2 <br /> Page Revised 8/2000 <br />