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THE AppLICANT HEREBY CERTIFIES: <br /> 1. That heJshe has read all the provisions of this application,and that the description included in this application are correctto 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 Joaqiun or any department,official or employee thereot;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 requested,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attache et,in luded as gen ral or special III provisions. <br /> S l�0 <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> FPIEPES: <br /> »»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> ': None � Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor)(p ) ❑ Paved(Good) ❑ <br /> Away from Pavement � Towards Pavement ❑ Flat ❑ <br /> None E�t' Existing-Type <br /> Other pipes in neighborhood: Yes 1�Vo ❑ Approaches ❑ Cross Drain ❑ Size a , <br /> Attachment to neighbor's pipe: Yes ❑ Nopa 1 <br /> 4. HEADWALL: Yes L'1 No ❑ <br /> xs i x f>> u 4 <br /> 5. ASPHALT CONCRETE DACE: Yes ❑ No Ek" " <br /> 6. BARRIERS along Right-of-Way ' <br /> 7. DITCH Yes L� No ❑ If Yes: V Style gal"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 Pipeinch <br /> Fla+ <br /> To be connected to any adjacent driveway pipe Yes ,❑ No Ei <br /> DRAINAGE INLET REQUIRED Yes ❑ No L7 <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...........................$8_9 <br /> Field Inspection <br /> 2�Driveway w/or w/o pipe.................................................$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/boxCutvert.................................................$155.00 ❑ Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />