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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 bast ofhis/har <br /> knowiwdge;and <br /> 2. That hofshe is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. That h6she 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 tl he shall <br /> defend,indemnify and hold them and each of theist 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 R gbt-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 offt and Any <br /> attached sheet,included as gen or ial gl <br /> r hire o <br /> t <br /> gnu f Applicant- ifle Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»'>»»»»EXISTING CONDITIONS««««««««««««««««<c««« <br /> 1. DRIVEWAY: Norte K Dirt ❑ Gravel ❑ Aggregate Base [] Paved(poor) ❑ Paved(Good) <br /> 2. SLOPING: Away&oprPatrement (D Towards Pavement ❑ Flat ` <br /> 3. PIPES: None Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No ®` Approaebm ❑ Crams Drain © Size <br /> Attachment to neighbor's pipe:,. Yes ❑ No [r <br /> 4. HEADWALL: Yes ❑ No ER"`"' <br /> 5. ASPHALT CONCRETE DIKE: Yes Q No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No Q'', If Yes: V Style ❑ 2 Point [] Other ❑ Width <br /> Dqft <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS««««««««««««<««<<<<< << <br /> 1. DRIVEWAY: SFR [ COMMERCIAL ❑ AGRICULTURE [ WKISTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over <br /> "Min.Depth 3/4"A.B. <br /> Notes E - <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 [2"' <br /> Total Length: -_._..(with proposed) Total Number of Stoma Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes [] No <br /> 4. PAVED FRONTAGE: PAVED with "Mi <br /> n Depth A.C.over ...._.._._. , Min.Depth 3/4 A.B. <br /> Measuring --- Feet in length and Feet in width <br /> FEES <br /> [Zield <br /> way Encroachment Permit base fee............................$85.00 <br /> nspection <br /> veway W or w-o pipe...............................................$95.00 <br /> u Paved frontage.... ... .........$100.00+0.461ft <br /> Driveway w/boxCulvert............................... ................$155.00 a Curb,Gutter,Sidewalk................. $I00.00+0.gadt <br /> Countee Computer,crAccess�Application for Permits`Driveway and Paved Frontage Pa 2 of 2 <br /> -- Revrse+d910M <br />..... <br />