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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 h s/ler <br /> knowlwdge;and <br /> 2. Teat 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 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 pennis ion is granted as requested,he agrees to do the work described in accordance with all terms,conditions and restrYction of this and any <br /> attached sh 1 e gen special III r 'ions. <br /> Vpw l clek, �. I Li a <br /> V n <br /> Signature of Applicant-Title <br /> Date <br /> FIELD INSPECTOR COIVFMENTS <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None 12' Dirt ❑ Gravel <br /> ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING, Away from Pavement <br /> [3}/ Towards Pavement E] Flat ❑ <br /> 3. PIPES: None 11 Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches APP'r ❑ Cross Drain ❑ Size <br /> Attaclunent to neighbor's pipe: Yes ❑ No [� <br /> 4. HEADWALL: Yes ❑ No [E <br /> 5. ASPHALT CONCRETE DHCE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V le — –`-- <br /> Sty ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»>»»»»»»»»»»»»»>»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [P-' COMMERCIAL, ❑ AGRICULTURE <br /> ❑ 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 [9 No ❑ <br /> DRAINAGE INLET REQUIRED Yes ❑ No ❑/ <br /> Total Length; (with proposed) Total Number of Storm <br /> Notes Drain Inlets <br /> 3. HEADWALL Yes ❑ No E <br /> 4. PAVED FRONTAGE: PAVED with ____"Min._"Min.Depth AC.over <br /> "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> Driveway Encroachment Permit base fee............................$85.00 FEES <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe.................................................$95.00 <br /> ❑ Paved frontage..................................$100.00+0.461 <br /> ❑ Drivewayw/boxCulverL................................................$155.00 <br /> ❑ Curb,Gutter,Sidewalk.......................$100.00+O.9g/g <br /> Coumer\Computer,c:`Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 <br /> g Revised 8/2000 <br />