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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 /> knowhvdge;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 inay arise out of the work described above, <br /> or winch 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 of the 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 III provisions. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base A-f Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement F01"' Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes LTJ No ❑ Approaches ❑ Cross Drain ❑ Size F-4, <br /> Attachment to neighbor's pipe: Yes El No [4�- —i —"�— <br /> 4. HEADIb'ALL: Yes ❑ No [b�' r7 <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes [ No y❑ If Yes: V Style []' 2 Point ❑ Other ❑ Width ®� Depth ' <br /> >»»»»»»»»»»»»»»»»»>>"�»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [� COMMERCIAL ❑ AGRICULTURE <br /> ❑ INDUSTRIAL <br /> PAVED with _W_'Min.Depth A.C.over <br /> Mm.Depth 3/4"A.B. <br /> Notes <br /> I' <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 GI/ <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes —❑ No <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 /> LJ Driveway w/or w/o pipe.................................................$95.00 f <br /> __i Paved frontage..................................$100.00+0.461ft <br /> Driveway w/box Culvert.................................................$155.00 J Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:`.Access\Apphcation for Perrnits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />