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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 included in this application are correct to the best of his/her <br /> knowlwdge;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 Joaquin or any department,official or employee thereot;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 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 granted as requested,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,included as general or special III provisions. -7 <br /> _ � 4I l.v Y�_a.L IQ G G6 <br /> Signature of Applicant-Title Dal <br /> FIELD INSPECTOR CONU ENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None $Z Dirt ❑ Gravel ElAggregate Base ❑ Paved(poor) ElPaved(Good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Existing-Type <br /> Other pipes in neighborhood: Yes N No ❑ Approaches ❑ Cross Drain ❑ Size LTJC Xi P S/m <br /> i <br /> Attachment to neighbor's pipe: Yes El No <br /> q. El No G RP Njs <br /> 4. HEADWALL: Yes <br /> S. ASPHALT CONCRETE DIf Yes ❑ No (k <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes C. No ❑ If Yes: V Style K 2 Point ( Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL X AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes' <br /> 2. PIPES: Leagth of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No [X <br /> DRAINAGE INLET REQUIRED Yes ❑ No .® <br /> Total Length: (with proposed) Total Nmnber of Storm Drafn Inlets <br /> Notes <br /> 3- HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mia Depth AC.over "Min.Depth 3/4"A.B. <br /> Measuring Feet 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...............................................$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Drivewayw/boxCulvert.................................................$155.00 ❑curb,Gutter,Sidewalk......................$i00.00+0.98/ft <br /> Coin\Computer,c:\Access\Application for Permits0riveway and Paved Frontage Page 2 of Revised 8/2000 <br />