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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 hisilter <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 may arise out of the work described above, <br /> or which may arise out of his/her failure to do tite work provided herein;and <br /> 4. That in the event any claim of such Iiability 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 terns,conditions and restriction of this and any <br /> attached sheet,included as general or special III provisions. <br /> Signature of Appticant-Title -- <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> FPIPES: <br /> >>»»»»>>:`>>>>=>EXISTING CONDITIONS<<<««««««<<<«««««««««««': None J Dirt ❑ Gravel Aggregate Base ❑ Pavzd(poor) ❑ Paved(Good)Away from Pavement ❑ Towards Pavement ❑ Flat <br /> None Existing-Type <br /> Other pipes in neighborhood: ^ �Yzs D No a__...�.w...�._._._....- <br /> Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No ] <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIKE: Yes [,] No ❑�] <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V le 2 Point <br /> Sty ❑ ❑ Other ❑ Width <br /> »»»»»»»»»»»»»»»»»>»»>PERMIT REQUIREMENTS«««««««««««««««««<<<<<< <br /> 1. DRIVEWAY: SFR X COMMERCIAL, ❑ AGRICULTURE <br /> ❑ INDUSTRIAL ❑ <br /> PAVED with <br /> Min.Depth A.C.over ^Min.Depth 3/4"A.B. <br /> Notes I -- --- <br /> 2• PIPES: Length of Pipe Required: y 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: (withproposed) <br /> _(wTotal Number of Storm Drain Inlets <br /> Notes <br /> i <br /> 3. HF,ADWALL Yes No �❑ — — — ---- <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC.over <br /> _.__.___.,...�..�.. "iVtin.Depth 34"A.B. <br /> Measuring T _ T Feet in length and Feei in width <br /> ------------- <br /> FEES <br /> [Field <br /> eway Encroachment Permit base fee............................585.00 <br /> Inspection <br /> Driveway w'orw opipe.................................................595.0(1 Paved frontage..................................S 10o.00-0.4641 <br /> Driveway w,bos Culvert.................................................5I55.00 <br /> �' Curb,Gutter,Sidewallc.......................51 oQOO-0.98!ft <br /> Counter`.Computer,c:'Access�Application for PennitstDriveway and Paved Frontage Page 2 of 2 <br /> —.-- —_------ <br /> Revised 8/2000 <br />