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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 i nthis 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 irgusyordamage to property which may arise out ofthe work described above, <br /> or which may arise out of his/her failure to do the work provided ham;and <br /> 4. That in the event any claim of such liability is made against the County of San Joagam or my department,official or employee thereof;he shall <br /> defend,indemnify and hold them and each of them harmless for such claves and <br /> 5. That work shall be performed by the applicant and/or any drive of the applicant in the Conaty Right-o€-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 or special III provisions. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COAEUEN'TS <br /> »»»»»»»»»»»»»»»»»>?»>>EXiSTMG CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Mase ❑ Pav«lccpoor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None A Mdsting-Type <br /> Other pipes in neighborhood Yes ❑ No Approaches ❑ Cres Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No„ 9 <br /> 3. ASPHALT CONCRETE DffcC : Yes ❑ No J <br /> 6. BARRIERS along Rigbt-c£Way <br /> 7. DITCH Yes ❑ No IfYes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR t' COMMERCIAL F-1AGRICULTURE E] INDUSTRIAL ❑ <br /> PAVED with "Mia Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Required: Pt.and Diameter of Pipe —�— Inch <br /> To be connected to any adjacent driveway pipe Yes El No Lr <br /> DRAINAGE INLET REQUIRED Yes ❑ No B/ <br /> Total Length: (with proposed) Total Nmiber of Storm Drak Inlets <br /> Nates <br /> 3. HEADWALL Yes A No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Measuring Fed in kno and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Fie tion <br /> Driveway w/or w/o pipe................................................$95.00 ❑Paved frontage.............._..............$100.00+0.46/6 <br /> ❑Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.98/6 <br /> Counta\Computer,c:\Access\Application for PenndslDnveway and Paved Frontage Pap of 2 Revised 8/2000 <br />