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THE APPLICANT HEREBY CERTH US: <br /> 1. That he/she has read all the provisions of this application,and that the description included intbis application are correct to the best of his/her <br /> knowhxdge,and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent the owner and <br /> 3. That helshe will assume full responsibility fw all liability far personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of limo r 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 Joagiva or any department,official or employee thereof;be shall <br /> defend,indemnify and holdthern and each ofthem 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 /> b. That if permission is granted as requested,he agrees to do the work described in acoardamce with alf terns,conditions andrestriction this any <br /> attached sheet,' general or special III pro <br /> Signature of Applicant-T9te Date <br /> FIELD INSPECTOR COAMENTS <br /> >/>>>>>>">>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>mC-nm CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: NoneM Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING. Away(fivai Pavement E] Towards Pavement ❑ Flat <br /> 3. PIPES: NoJM Eldsting-Type <br /> Other pipes in neighborhood: Yes rNo. Approaches ❑ Craw Drain ❑ Size <br /> Awt to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIICE: Yes ❑ No Ik <br /> 6. BARRIERS along Right-of--Way <br /> 7. DITCH Yes ❑ No Od Ifyes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR 'k COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Min.Depth A.C.over 4 "Mia Depth 3/4"A B. <br /> Notes SGl1Al� <br /> 2. PIPE& Long*of Pipe Required: It and Diamder 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 Naber of Storm Drax Islets <br /> Notes <br /> 3. HEADWALL Yes ® No FRI <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Min Depth 3/4"A.B. <br /> Measuring Fat in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fa............................$85.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.................................................$95.00 ❑Paved fraadage..............................$100.00+0.46/ft <br /> ❑Driveway w/bos Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> CounterlComputer,c:\Access\Application for Permits0rivewaky and Paved Frontage Page 2 of 2 Revised 8/2000 <br />