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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/aha has read all the provisions ofthis appficationi and that the description inckxkd M- this <br /> application ate con+ad to the best of hisJher , <br /> knowtwdge,and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent&a own w,and <br /> 3. That he/she will assume full trspoasihility fat aft liabitnty far Personal injury or damage to prop,v�iChmay arise out of the work descaibed above, <br /> or which may arise out ofhis/her failure to do the work provided herein;and <br /> 4. That in the event any claim ofauc h liability is made against the County QfSan Joacpm or any department official oree <br /> �Y �he shall <br /> defend,indemnify and hold them and each ofthem harmless for such claire;and <br /> 5. That work shall be perfarmad by the applicant and/or any representative of&c applicant m the County Right-0f-Way at the above indicated site <br /> with a valid San Joaquin County Encroadkneut Perms and <br /> 6. That if permission is granted as requested,he es to do the wads desmdbed in acombmwe vA&all tents,conditions and restriction of this and any <br /> attached sheet,' as general of sp visions <br /> Z7 O <br /> Signature of Applicant-Title <br /> Date <br /> FIELD INSPECTOR COACMENTS <br /> »»»»»»»»»»»»»»»»»»»» <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel UL Aggregate Base ❑ Ptv.",) [] Pav*Good) ❑ <br /> 2. SLOPING: Away1kom Pavmrant ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Now ❑ E dsd -Type ?Z," baleII&A'WD <br /> Othcrp mnei�d: Yes M No ❑ Approach.. X Cross Drain ❑ Stye <br /> Attachment to Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DUM: Yes ❑ No <br /> 6. BARRIERS along Right-of Way <br /> 1. DITCH Yes A, No ElIf Yes: V Style 2 point El Other El Width Depth <br /> >">'»»»»»»»»> »»»»»»»»>PERMIT REQUIREMENTS<z««««««««««««««««««« <br /> L DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with ^Int Depth A.C.over —±_"Min.Depth 3/4"A.B <br /> Nates <br /> L PIPES: Lath of Pipe Reqaired: Ft.and Dimater of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> TOW (with Proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes R No <br /> 4. PAVED FRONTAGE: PAVED with "ldn.Depth A.C.over "Max Depth 3/4"A.B. <br /> Measuring Feel in tenth and Fed in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................585.00 <br /> k <br /> Inspocflon <br /> riveway w/or w/o pipe........._..._....._....__..-............$95.00 ❑ :rivewayw/boxCalveR........_....._......._......................$155.00 ❑Curfi,(iutter,swewa&.........._.........$100.00+0.98/R <br /> CountaiComputer,c:\Acoeas age. Revised 8/2000 <br /> Wpplioation for Pamits�Driveway a�Paved Frontage P 2 of 2 <br />