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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That helshe 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 /> knowlwdge,and <br /> 2. That heJshe 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 far personal mjary or damage to property whichmay arise out of the work described above, <br /> or which may arise out of hm4w failure to do the wont provided herein;and <br /> 4. T'bat in the event any claim of such liability is made against the Courcy of San Joagiun or any department official or employee thereo&he shall <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 and/or any rive 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 /> 6. That if permission is granted ashe agrees to do the wads described in accordance with ail terms,conditions and restriction of this and any <br /> attached included as anerai visions. <br /> of Applicant Tine Date <br /> FIELD INSPECTOR COA MENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Pv*G,(,d) ❑ <br /> 2. SLOPING: Away from Pavament Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: Now Esist W-Type <br /> Ether pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neigW)oes pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPSALT CONCRETE DB a Yes ❑ No <br /> 6. BARRIERS along Rigbt-cf Way <br /> 7. DITCH Yes ❑ No If Yes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREXIENTS«««««««««««««««««««« <br /> 1-DRIVEWAY: SFR jk COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Min.Depth A.C.eve "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPES: Length of Pipe Regoirpd: Ft and Diaanatrr e£Pare Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total 1,ength (with proposed) Total Number of Storm Drain Inlela <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee........................ ..$85.00 <br /> Fie hon <br /> Driveway w/or w/o pipe.............................._.._..........- 5.40 ❑Paved fi antage_......_. . _ ...___..$1{)0.00+0.46/ft <br /> ❑Driveway w/box Culvert................................................$ 5.00 ❑Curb,Gutter,Sidewalk..............._.....$100.00+0.98/ft <br /> Ceunter\Computer,c: \Application for Permits0riveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> t <br />