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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 hisiher <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 Joagiun or any department,official or employee thereof,he shall <br /> defend,indemnify and hold them and each of them ham-Jess 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 percussion is granted as requested,he agrees to do the work described in accordance with all terms,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 COMMENTS <br /> »»»»»»»»»»»>»»»»>>>>>EXISTING CONDITIONS<<<«««u<«««<««««««««««< <br /> 1. DRIVENVAY: None T", Dirt Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None LJ Existing-Type <br /> Other pipes in neighborhood: Yes w❑ No_ Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No [L�" <br /> 5. ASPHALT CONCRETE Dr E: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No [4?' If Yes: V Style ❑ 2 Point ❑ Other ❑ Width _ Depth <br /> »»»»»»»»»»»»»»»»»»>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVENVAI': SFR ❑ COMMERCIAL LJ AGRICULTURE ❑ INDUSTRIAL ❑1 <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe A Inch _�^ <br /> To he connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No CLY <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes � -- -- — ----- <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A-C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee....._.....................585.00 <br /> Field Inspection _ <br /> J Driveway w,or wio pipe.................................................595.00 v �' Paved frontage.................................5100.00 T 0.46;f1 <br /> Driveway"box Culvert..............................._....,..,........S155.00 _J Curb,Gutter,Sidewalk.......................5100.00+0-9841 <br /> CounterComputer.c:Access�Application for Permi&Driveway and Paved Frontage Page 2 of 2 Revised 8'2000 <br />