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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the descriptions included above are correct to the best of his/her. <br /> knowledge; 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 <br /> described above,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 Joaquin or any department,official or employee <br /> thereof,he shall 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 representatives of the applicant in the County Right-of-Way at the aboN <br /> indicated site 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 <br /> restrictions of this and any attached sheet,included as general or special III provisions. <br /> 1 -1 <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»> »»»»»»EXISTING CONDITIONS««««««««««««««« <br /> 1. DRIVEWAY:None Dirt Gravel Aggregate Base Paved(poo Paved(Good) <br /> 2. SLOPING: ay from Pavement Towards Pavement Flat <br /> w <br /> 3. PIPES: None Existing-Type <br /> Other pipes in neighborhood: Yes No K Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No <br /> 4. HEADWALL: Yes No K <br /> 5. ASPHALT CONCRETE DIKE: Yes No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes No 'M- If Yes: V Style 2 Point Other Width Depth <br /> »»»»»»»»�»»»»»»>PERMIT REQUIREMENTS««««««««««««««« <br /> 1. DRIVEWAY: SFR OG C RCIAL AGRICTURE INDUSTRIAL <br /> PAVED with "Min.Depth A.0 over Min.Depth%"A.B. <br /> Rocked with "min.Depth%" 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 NoK <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 A.0 over "Min.Depth 3/."A.B. <br /> Measuring Feet in length and Feet in width <br /> K FEES <br /> Encroachment Permit base fee ...................$ &� <br /> Field IrlWectionuYlbriq�aD <br /> veway w/or w/o pipe .............$fid p Paved Frontage..............$80.00+ .37/ft <br /> p Driveway w/Box Culvert ............$125.00 p Curb, Gutter, Sidewalk.....$80.00 + .78/ft <br /> C:1Documents and SettingslepageWy DocumentsTorms and Template0riveway permit application(reverse side).doc <br />