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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 mck ded inthis application are correct to the best of his/her :. <br /> knowlwdge;and <br /> 2. That helshe 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 persomi injury or damage to property whish 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 Sam Joao or any depmrtment,official or employee thereof;he shall <br /> defend,imdem ify and hold them and each of them harmless for such claims;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Riot-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Perrrnit;and <br /> 6. That if permission is granted as requested,he agrees to do the work descrribed in accordance with all teens,conditions and restriction of this and any <br /> attac d sheet,inchrded general or special III provisions. y <br /> Signature of Applicant-Title Dae <br /> FIELD INSPECTOR COMMENTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nene A Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Avm,y((&an Pavement EJTowards Pavement [� Flat E)3. PIPES: Now /LSI- Existing-Type <br /> Other pipes innei&borhood: Yes ❑ No ig Approaches ❑ Cross Drain ❑ Size <br /> Attacbme t to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yea ❑ No <br /> S. ASPHALT CONCRETE DYea ❑ No <br /> 6. BARRIERS along Rigid-cf Way <br /> 7. DITCH Yes ❑ No k If Yea: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with __ Af Mia Depth A.C.over "Mm.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Requirod Ft.and Dianidw of Pipe inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No X <br /> Total length: (with proposed) Total Nunber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Mia Depth3/4"A.B. <br /> Measuring Fed in lenglh and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Field Inspection <br /> ❑Drivewayw/or w/o $95.00 ❑ Paved .... $100.00+0.46/ft <br /> pipe..........................._._...-----...... Sra�odage..._..... . __............... <br /> ❑Driveway w/box Culvert...............................................315.5.00 Curb,Gutter,Sidewalk.......................$100.00+0.98hl <br /> CountaAComputer,c:\Access\Apphc&bon for Permits0riveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />