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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 iachxled in this application are correct to the best of his/her <br /> knowhvdge;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 hL-Aff 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 Joagam 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. That if permission is granted as requested,he agrees to do the work described in accordance with all teams,conditions and restriction of this and any <br /> attar t,' chided as g� ar�e IIi provisions. � /� <br /> Si of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»>>EXISTING CONDMONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Nome ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ® Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Now ❑ Existing-Type 7-4 $ <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 DIIM: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes JA No ❑ If Yes: V Style 10 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR K COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over '.Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Retpured: Ft.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 Draie Inlets <br /> Notes <br /> 3. HEADWALL Yes Q No Q <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..............................................(.=$95-0011- ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑Driveway w/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:4Access\Applicatiom for Pe=U\Dnveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />