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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 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 Rill 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 perfo by the applicant and/or any representative of the applicant m the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin ou iy Encroachment Permit;and <br /> 6. That if percussion is graate s requested,he agrees to do the work described in accordance with all terns,conditions and restriction of this and any <br /> alta c e e e <br /> C7 <br /> Signature of App can- r e Date <br /> FIELD INSPECTOR COMMENTS <br /> FPIPES: <br /> »>»»>»»»>»»»»»>>»»»>EXISTING CONDITIONS«««««««««««««««««««« <br /> : None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> Away from Pavement ❑ Towards Pavement ❑ Flat E9- <br /> 3. None Existing-Type <br /> Other pipes in neighborhood: Yes No ❑ Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No Rr <br /> 4. HEADWALL: Yes ❑ No [9' <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No [�] <br /> & BARRIERS along Right-of-Way <br /> 7. DITCH Yes 4?!r No ❑ If Yes: V Style [R"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"AB. <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 P' <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 AC.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.OD <br /> Field Inspection P�Driveway w/or w/o pipe......................................... 5.00 EJ. Paved frontage..................................5100.00+0.46/ft <br /> ivewayw/boxCulvert.................................................$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CounterlComputer,c:'Access\Application for Permits0riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />