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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read alt 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 /> or personal injury or damage to property which may arise out of the work described above, <br /> 3. That he/she will assume full responsibility for all"andity f <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 Joagwn or any department,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. Tbat if permission is granted as requeste he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached eat,' eluded as g special III provisions. <br /> ><- 7-2--C- 0 6 <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR CONINIENTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None A, Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away firm Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None 54 Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches F1 Cross Drain El Size <br /> Alert to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No 54 <br /> 5. ASPHALT CONCRETE DHM: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way AJI <br /> 7. DITCH Yes ❑ No U4 If Yes: V Style ❑ 2 Point ❑ Other f-] Width Dept <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [;jj,. COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with Min Depth A.C.over _� Min.Depth 34'AB. <br /> Notes <br /> 2. PIPES: Length of Pipe Regako : It and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length (with proposed) Total Number of Storm Draft Islets <br /> Notes <br /> 3. HEADWALL Yes R No (� <br /> 4. PAVED FRONTAGE: PAVED with "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...........................$85.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe............................................. .$95.fl0 ❑ Paved frotrtage.................._--------------$100.00+0.46/ft <br /> ❑ Drivewayw/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:lAccess\Application for Permits\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />