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THE APPLICANT HEREBY CERTIFIES: <br /> I. 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 his1ier <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 Joagiun 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 oft1ris and any <br /> attached sheet,included as general specia II provisions. <br /> Signature of Appli t-Title Date <br /> FIELD INSPECTOR COMNIENTS <br /> »»»»»»»»»»»»»>»»>>»>»>>E)USTING CONDITIONS«««<«<<<<«««««««««««««< <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel [� Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away,from Pavement ❑ Towards Pavement ❑ Flat ©' <br /> 3. PIPES: None ❑ Existing-Type 12 IV <br /> Other pipes in neighborhood: Yes �No ❑ Approaches ❑ Cross Drain ❑ Size /Z 'Y <br /> Attachment to neighbor's pipe: Yes Lk'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 ❑ If Yes: V Style [�r 2 Point ❑ Other D Width �Ya Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««<<«««««««««««««««« <br /> 1. DRIVEWAY: SFR p- 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^w Inch— <br /> To be connected to any adjacent driveway pipe Yes ❑ No ❑ <br /> DRAINAGE INLET REQUIRED Yes No ❑ ����r� �''� Vn � s/G� �� <br /> QGt,Lf OY 0 turf <br /> Total Length: (with proposed) Total Nunnber of Stortn DtyCm 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 T YT Feet in length and FR Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................S85.0P____ <br /> Field Inspection <br /> Driveway w/or w/o pipe.................................................S95.00Paved frontage..................................$100.00+0.46ift <br /> Driveway wibox Culvert-................................................$155.00 Curb,Gutter,Sidewalk-.....................$100.00+0.98 ft <br /> Counter\Computer,c:\Access\Application for PermitslDriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />