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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 corect to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner ofthe 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,indemnify and hold them and each of them hamiess 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,lie agrees to do the work described in accordance with all terns,conditions and restriction ofthis and any <br /> attached sheet,incl a>� s geiler�l or special III provisions. <br /> SignahrreofApplicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »> >»»»»»»»»»»»»»>>»>>»=E�USTING CONDITIONS««c;«««<<««««««««««««« <br /> 1. DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved{Good) [L]� <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes [4�'No ❑ Approaches ❑ Cross Drain ❑ Size <br /> -,/ <br /> Attaclurrent to neighbor's pipe: Yes LJ No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPIIALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes �No M[_]_. If Yes: VStyle [t?�2 Point ❑44v Other ❑ Widthy�wry� Nc wM1 p DepthY'^ <br /> »»»»»»>»»»»»>»>»»»»>>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [�J' COMMERCIAL ❑ AGRICULTURE E INDUSTRIAL ❑ <br /> PAVED with _v Min.Depth A.C.over .. Min.Depth 3/4"AB. <br /> Notes — <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be cormected to any adjacent driveway pipe Yes ❑ No _._lk <br /> DRAINAGE NLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Nuiuber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC.over "11vlm.Depth 3/4".4B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................585.00 <br /> Field Inspection <br /> i-- <br /> L_ Drivewav w;'or wdo pipe............................................._S95.o0 J Paved frontage..................................5100.00-0.46JI <br /> L Driveway w/box Culvert.................................................5155.00 Curb;Gutter,Sidewalk.......................SU10.00-0.98'ft <br /> Counter`.Computer,c:'Aceess`Appiication for Permits\.Driveway and Paved Frontage Page 2 of 2 Revised 8%2000 <br />