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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 lter <br /> knowlwdge;and <br /> 2. That lye/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 wduch may arise out of the worn: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 requ ted,Ile agrees to do the work described in accordance with all terns,conditions and restriction of this and any <br /> attached sheet/mclu ed as gener of ecial III provisions. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> EXISTING CONDITIONS<<<<<<-"<««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ® Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat J� <br /> 3. PIPES: None ❑ Existing-Type u <br /> Other pipes in neighborhood: Yes No ❑ Approaches ❑ Cross Drain ❑ Size 12 <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No 4KJ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes K No If Yes:~„ V Style �2 Point E] Other`�' Width� 7 vDepth <br /> »»»»»»>>»»»»»»>»»»>>>>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR �4 COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <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 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 /> Notes I -- ----- ---- ----- -----_ <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC.over "klin.Depth 3 4"A.R <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.06 <br /> Field Inspection <br /> ❑ Driveway w;'cr w/o pipe................................................595.00 Paved frontage._...............................SI 00.00-0.4641 <br /> Driveway w-lbox Culvert.................................................S155.00 Curb,Gutter,Sidewalk.......................5100.00-0.98 ft <br /> Counter\Computer,c:`.Access-Application for Permits`,Driveway and Paved Frontage Page 2 of 2 Revised 812000 <br />