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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the descriptiom 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 ofthe 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 Wit,official or employee thereof;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 terns,conditions and restriction of this and any <br /> attached sheet,in used as special visions. <br /> -7-/2 - o6 <br /> Si of Applicant-Title Date <br /> FIELD INSPECTOR COAUKENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDMONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) 1K Paved(Good) ❑ <br /> 2. SLOPING: Away from Pave neat Towards Pavesmew ❑ Flat ❑ <br /> 3. PIPES: None (Z Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DUCE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way Pj A <br /> 7. DITCH Yes ❑ No i4 dyes: V Style ❑ 2 Point ❑ Other ❑ Width Doh <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> I. DRIVEWAY: SFR 5j!(. COMMERCIAL ❑ AGRtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "Min Depth A.C.over _ 4 -Mia Depth 3/4"AB. <br /> Notes <br /> 2. PIPE& Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway tripe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No R <br /> Total Length: (with proposed) Total Number of Storm Drala Feta <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mia 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...........................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe............................................ ..$95.00 ❑Paved&ontage..................................$100.00+0.46/ft <br /> El <br /> Driveway w/box Culvert.................................................$155.00 ❑curb,Gutter,Sidewallc.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits0riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br /> A'A"PCr�60 <br /> rmi� pelw ,w &deo Aar4ei- d,�dde�pgJt�l� er1�A?rts/s �si�� 4o�rai 01 01� . <br /> 1.'e. .4 (o7— j;0o —O�IJ paJ <br />