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"HEREBY CERTIFIES: <br /> 'he provisions of this application,and that the description included in this application are correct to the best of his/her <br /> the owner of the respective property,or is qualified to represent the owner,and <br /> s tie/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 thereo4 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 in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachm ermit;and <br /> 6. That if permission is granted as re d, a ees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet included as gene al III provisions. r L Z <br /> of Applicant-Title /%IY Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»>; »»»»»EXISTING CONDITIONS«««««««««««««<�««««< <br /> 1. DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement T Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type 12 'to dA4�R <br /> Other pipes in neighborhood: Yes [kNo ❑ Approaches ❑ Cross Drain ❑ Size /2 �� <br /> Attachment to neighbor's <br /> pipe: Yes �No ❑ <br /> 4. HEADWALL: Yes [:] No L�-,pe <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No E91 <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ER'No ❑ If Yes: V Style 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Ee COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <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 5" <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No [P' <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.................................................$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/box Culvert.................................................$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />