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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 lter <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 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 Applicant-Title Date <br /> FIELD INSPECTOR CONINIM NTS <br /> »»»=>>»>»=»»»>>»»>»EXISTING CONDITIONS«««««<<«««««««««««««« <br /> 1. DRIV NVAY: None ❑ Dirt Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None F9 Existing-Type <br /> Other pipes in neighborhood: c e Yes` EJ No X Approaches ❑ Cross Drain ❑ Size <br /> Attaclunent to neighbor's pipe: Yes ❑ No <br /> 4. READNVALL: Yes ❑ No Yom+ <br /> 5. AS MALT CONCRETE DIKE: Yes ❑ No (� <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No 54 If Yes: V Style [ ] 2 Point ❑ Other ❑ Width Depth <br /> »»».»»»»»»»»»»»»»»»>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR A COMMERCIAL ❑ AGRICULTURE <br /> ❑ INDUSTRIAL [] <br /> PAVED with 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 connected to any adjacent driveway pipe Yes ❑ No ❑� _� _ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> v_ <br /> Notes r-- - --- —— - --— - - — - <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and _ Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee <br /> ..................... <br /> Fie d Inspection <br /> Driveway or w/o pipe................................. ..... 9 <br /> Paved frontage..................................$I00.00+0.46ifi <br /> Driveway wvbos Culvert.................................................$155.00 L Curb,Gutter.Sidewalk.......................5100.00-0.98%fl <br /> Counter,Computer,c:'.Access'Application for Penmits"Driveway and Paved Frontage Page 2 oft Revised 812000 <br />