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TIDE AppLICANT HEREBY o f application,this s and that e included in this application are correct to the best of limber <br /> 1. That he/she has read all the provisions <br /> knowlwdge;and <br /> qualified esent the owner;and <br /> 2. That he/she is the owner ofthe respective property, is ed to <br /> 3. That he/she will assume full responsibility <br /> for all liability far personal injury or damage to property which 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 <br /> is made against the County of San losgam or any depart,official or employee thereof;be shall <br /> defend,indemnify and hold them and each of them harmless for such claim;a� -0f Ws at the above indicated site <br /> 5. That work shall be performed by the applicant and/ <br /> any representative of the applicant in the Courtly ght Y <br /> with a valid San Joaquin County Encroachment <br /> and conditiand restriction of this and any <br /> 6. That if pemvssion is granted as yepu-Ud,he agrees to do the work described Tri accordance with all Terms, ons <br /> provisions. <br /> ,! attached sheeOncluded ce sP <br /> Date <br /> vL Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»>>>>—>>>EXISTING CONDITIONS««««««««<<<<< «««««« <br /> Nome A Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) El1. DRIVEWAY: <br /> Z. SLOPING: E)AwaY from Pavement Towards Pavement ❑ Flat <br /> 3. PIPES: None R Ex�stmg-Type <br /> tomer Pipes in neiglYes No D . Approaches El cross Dain El Sm <br /> { <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DUKE: Yes ❑ No <br /> 6 BARRIERS along Right-of-Way 4 <br /> th <br /> 7. DITCH <br /> Yes El No �. If Yes: V Style ❑ 2 Point El Other ❑ Width Dep <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««<<<<<<««««««««««« <br /> 1. DRIVEWAY: SFR <br /> COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "Min.Depth A.C.over _�_"Mm Depth 3/4"A.B. <br /> Notes <br /> 1 2. PIPE6 L.eth of Pipe Required: Ft and Diameter of Pipe <br /> Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> FA <br /> DRAINAGE INLET REQUIRED Yes ❑ No 62 <br /> Total Ungth: (with proposed) Total Number of Sturm Drads Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED with <br /> Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................A85.00Y <br /> Feld Inspection $100.00+0.46/ft <br /> 0 ❑Paved framtage_................_.............. <br /> Driveway w/or w/o pipe................................._....._......... $100.00+0.98/ft <br /> ❑ Driveway w/box Culvert........................................ <br /> $1 ❑Curb,Gutter,Sidewalk..................... <br /> Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Accs\Application for Permits\Driveway and Paved Frontage <br /> es <br />