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THE APPLICANT HEREBY CERTIFIES: <br /> I. 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 /> 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 Joagmn 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 pen ' ' n. granted as requested, agrees to do the work described in accordance with all terns,conditions and restriction of this and any <br /> attache sheet,' u as al al III provisions. <br /> X � p <br /> i lure of Applicant-Title ate <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»>>»»»»»»»»>»»»»>EXISTING CONDITIONS««««««<<««««««««««««« <br /> DRIVEWAY: None ❑ Dirt ❑ Gravel [� Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> F2. SLOPING:: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type 1,�nk/"g )q t" eet�tit,' •�o. Gnp/�tfe�s /n/�✓ce <br /> Other pipes in neighborhood: Yes E4-No proaehes ❑ Cross Drain ❑ Size /Z <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No ❑-- <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No 5;- <br /> 6. BARRIERS alongRigbt-of-Way <br /> 7. DITCH Yes ©'-No ❑ If Yes: V Style [a'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 F_ <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 <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............................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.................. .........................$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/box Culvert.................................................$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:lAccess\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />