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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read ad the provisions of this application,and that the description included in this application are correct to the best ofhis/her <br /> knowiwdge,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 an liability fain Personal injury or damage to property which may arise out of tbe 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 Comity of San Jbagkm or any deparimant,d5ciai or employee thereof he shah <br /> defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant t and/or any eve of the applicant in the County Rim-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit and <br /> S. That if permissim is gray i a requeste to do the work describedin acocidance with all terns,conditions and 7i7s—� <br /> and y <br /> attached sheet,included as g prove, bS— <br /> Signature ofAPPlicant Title Date <br /> FIELD INSPECTOR CUMhIENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nme ❑ Dirt ❑ Gravel Aggregate Base ❑ Pavod(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING. Away from Pavement ❑ Towards Pavement ❑ Fla ❑ <br /> 3. PIPES: Name ❑ Existing-Type <br /> Other Pipes in mood Yes k No C' ApproachesCross Drain ❑ Size <br /> E4�e <br /> Alert to neighbor's Pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIICE: Yea ❑ No <br /> 6. BARRIERS along Rigla-cf Way <br /> 7. DITCH Yes No If Yes: V Style 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUER EMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 'Min.Depth A.C.over <br /> �_"Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of pipe —�-- Indy <br /> To be connected to any adjacent driveway pipe Yea ❑ No C�-- <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> kf– <br /> Total Length. (with proposed) Total Number of Storm Drain Inleb <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mia Depth A.C.over "Mia Depth 3/4"A.B. <br /> Meng Feet in length and Fed in width <br /> FEES <br /> Driveway <br /> ,,Encroachment Permit base fee............................$85.00 <br /> F�" v <br /> m <br /> w/or w/o pipe........._..................._................$95.00 ❑Paved fiwA e.. ...._....$100.00+0.46/ft <br /> w/box Culvert-................................................$155.()o ❑Curb,Gutter,SidewalL......................$100.00+0.98/ft <br /> C-nterlComputer,cAAccesslAppliaatim for Permi0l)riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />