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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 his/her <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 hz'she will assume full responsibility for all liability for personal injury or damage to property which may arise out of the wod: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 terms,conditions and restriction ofthis and any <br /> attached sheet,included as general or special III provisions. <br /> — Awl,LGiHy hod 11lYser�� 0 �0�/6 Pi <br /> Signature of plicant-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> F1. DIVENV:4I': None ❑ Dirt Gravel ❑j Aggregate Base Paved(pdor) n Paved(Good) <br /> 2. SLOPING: Away from Pavement El< Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None L�-';r Existing-Type <br /> Other pipes in neighborhood: Yes m❑ No_ Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No P <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No [�' <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V Style [] 2 Point_❑^ Other E�A Widthw� Depth���� v µ <br /> »»»»»»>»»»»»»>>»»»»»»>PERMIT REQUIREMENTS«««««<<«««««««««««««« <br /> 1. DRIVEWAY: SFR, ❑ COMMERCIAL [1;, AGRICULTURE ❑ TNDUSTRIAL ❑ <br /> PAVED with Min.Depth A.C.over _ Nfin.Depth 3/4"A.B. <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 L�' <br /> Total Length: (with proposed) Total Number of Ston-rn Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ❑ No — —-- — - — — — <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............. <br /> Field Inspection <br /> Drive��a% w,or w o pipe,. .. .... .......... Paved frontage. .......5100.00 0.46 ft <br /> Driveway wibox Cuh7ert... .... ..,. ...5155.00 L Curb,Gutter,Sidewallc......................5100.00+0.98 ft <br /> Counter,Computer.c:lAccess,Application for Penmits'Drivewav and Paved Frontage Page 2 of Revised 8.%2000 <br />