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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 /> knowhvdge,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-a assume fnlf responsibility for all liability f-personal-Mor damage to property winch 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 Joagi m or any department,official or employee thereof he shall <br /> defend,indemnify and holdthem and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any rotative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroacfraart 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 ffi provisions. <br /> Signature of Applicant Tille Date <br /> FIELD INSPECTOR COMMENTS <br /> »>>EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Pavod(Poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awa from Pavement ❑ Towards Pavement Flat El3. PIPES: Now � Existing-Type <br /> Otber pipes in neighborhood: Yes El No Approaches ❑ Crass Drain El Size <br /> Attaclirneat to neighbor's Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPSALT CONCRETE DUM: Yes ❑ No X <br /> 6. BARRIERS along Ri&-of-Way <br /> 7. DITCH Yes ❑ No If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»P <br /> »»»»»»»>PERMIT REQUIItEMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL, ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 'Min.Depth A.C.over —4—"Min.Depth 3/4"A B. <br /> Notes �(1 :t 6077e <br /> 2. PIPE& L-Sth of Pipe Required: FL and Diameter of Pipe h ch <br /> To be connected to any adjac a t driveway pipe Yes d No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inieta <br /> Nortel <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Fi Id Inspection <br /> riveway w/or w/o pipe................................................$95.00 ❑ Paved fmrmntage...__.........._._ ...........$100.00+0.46/ft <br /> ❑Driveway w/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> Counter\Computer,c:WccessWpplicstion for Perri t Driveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />