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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 Joaqiun or any departxnent,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 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 /> attached sheet,included as general°y special III provisions. ° <br /> 1'` <br /> - Signature of Applicant-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»>»>>>»»»»»»»>»»»>>>>>>>>>EJLMSTNG CONDITIONS««««««««««««««««<,«««< <br /> DRIVEWAY: None ❑ Dirt [] Gravel � Aggregate Base ❑ Paved(poor) ❑ Paved(Good) <br /> 1. [) <br /> F2. SLOPEVG: Away from Pavement 1❑ Towards Pavement ❑ Flat (ti <br /> 3. PIPES: None ❑ Existing-Type — c! <br /> Other pipes in neighborhood: Yes [� 'No ❑ Approaches ❑ Cross Drain ❑ Size --] <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes Z No ❑ &'?0ac/ r� G /?,q %/?oaof fres <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No E? <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes [?' No ❑ If Yes: V Style Point ❑ Other ❑ Width — Depth _ -- <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [- <br /> W' COMMERCIAL. AGRICULTURE ❑ INDUSTRIAL 0 <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 ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes — ----- -- <br /> 3. HEADWALL Yes ❑ No <br /> LZJ <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over " 4fin,Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> __._.... FEES <br /> Driveway Encroachment Permit base fee....................... <br /> Field Inspection <br /> Driveway a or w:o pipe..............................................r..S9o.00,, Paved frontatre..................................5100.00 0.46%ft <br /> ❑Drivewavwrbox Culvert.............................................. 1 5.00 J Curb,Gutter.Sidewalk.......................S10o.Go--0.98%ft <br /> CountenComputer,cr.Access\Application for PermitskDriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />