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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 okver of the respective property,or is qualified to represent the owner,and <br /> 3. That he/she will assume frill 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 claire;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 perm-is ion-19--granted as requested,he agrees to do tine work scribed in accordance with all terns,conditi nd restiy.tier this and-m-i <br /> a sheet included as general or special III provisions. <br /> Signature of Applicant Title <br /> FIELD INSPECTOR COMNIENTS <br /> »»»»»»»»»»»»»»»»>>»»»EhTSTING CONDITIONS««««<«««««««««««««««< <br /> 1. DRFVENVAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No ❑ Approaches ❑ Cross Drain ❑ Size C� <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No ❑ <br /> 3. ASPfL4,LT CONCRETE DEKE: Yes ❑ No U <br /> 6. BARRIERS along Right-of-Way <br /> 7. DIT CH Yes ❑ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»>>>>>>>>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ 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 <br /> To be connected to any adjacent driveway pipe Yes ❑ No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No ❑ <br /> Total Length: (with proposed) Total Nmnber of Storni Drain Inlets ar�� <br /> - <br /> Notes <br /> 3. HEADWALL Yes ❑ No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth AC-over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................585.00 <br /> Field Inspection <br /> ❑ Drivewav w;or w/o pipe........................._......................595.00 JI Paved frontage..................................5100.00-0.46,ft <br /> IJ Drive ray w box Culvert............................................ ❑ Curb,Gutter,Sidewalk......................5100.00+0.98rft <br /> Counter\Computer,c:Access+Application for Permits!Driveway and Paved Frontage Page 2 of 2 Revised 8.2000 <br />