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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 connect to the best of his/her <br /> knowhadge;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 Joaqiun or any department,official or employee thereof;he shall <br /> defend,inderrn ify 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 ifpemnission is granted as requested,he agrees to do the work described in accordance with all tenns,.conditions and restriction of thus and any <br /> attached sh luded asI general or sp cia III p ovistons. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR CONINIENTS <br /> EXISTING CONDITIONS<<<<�<<r<<<«<<<«<<«««««««««« <br /> 1. DRIVENVAY: None ❑ Dirt ❑ Gravel I❑ Aggregate Base L_V�_ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑✓r <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: YesV ❑'No� L1 Approaches ❑ Cross Drain ❑ Size I�I � <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No ❑�' <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes 14�No If Yes: V Style E] 2 Point O--Other ]`ry Width Depth <br /> »»»»»»>»»»»»»>>»»»»>>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR V COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes - - --- <br /> 7 <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 6Fo� <br /> Total Length: (with proposed) Total Nunnber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No L� <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A-C.over "Nlin.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 /> I <br /> Driveway w,'or w/o pipe.................................................S95.00 Paved frontage............................ <br /> $100.00-r 0.46 ft <br /> Drivewa% box Culvert...............................................S1».00 Curb.Gutter,Sidewalk....................-S100.00+0.98-ft <br /> Counter!Computer.c:'.Access�Application for Pemnits"Driveway and Paved Frontage Page 2 of 2 Revised 8,'2000 <br />