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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That,helshe has read all the provisions of this application,and that the mom included in this application are correct to the best of his/her <br /> k9Dw1wdge;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 all liability for 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 is made against the County of San Joagiun or any department,official or employeethereof;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 arAl/or any representative 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 requ a to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attacd sheet,inchr visions. <br /> S' of -Title Date <br /> FIELD INSPECTOR COAINUNTS <br /> >>»»»»»»» >>>>>>»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) (g Paved(Good) [] <br /> 2. SLOPING: Away from Pavement YL-11TowardsPavement E] Flat iCt <br /> 3. PIPES: None ❑ Existing-Type fl/9dPlw�fd QX"YZ� C/ZP K� <br /> Other pipes in °Oil Yes (,� No ❑ Approaches ❑ Cross Drain ❑ Size -1 <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No JZ <br /> S. ASPHALT-CONCRETE DII Yes ❑ No <br /> 6. BARRIERS along Right-of-Way /V�A <br /> 7. DITCH Yes �A No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»>»»»»»»»»>>>>>>>»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> I. DRIVEWAY: SFR [X COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with ....... Min.Depth A.C.overMin.Depth 3/4"A.B. -- <br /> Notes " <br /> 2 PIPES: Length of Pipe Required: Ft.and Diarmater of Pipe Inch <br /> To be connected to any a4acent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Nmnber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over. ^Min Depth 3/4"A.B. <br /> MeasuringFeet in length and _Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee................. .. ..$85.00 <br /> Field Inspection <br /> ❑❑ Driveway w/or w/o pipe..............................................." yy ❑Paved&onto .$100.00+0.46/ft <br /> Driveway w/box Culvert.................................................$155.00 ❑Curb,Ch*w,Sidewalk.......................$100.00+0.98/ft <br /> Coanter\Computer,c:\Accesc\Application for Permits\Driveway and Paved Frontage Page 2 of 2 <br /> Revised 8/2000 <br />