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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 inn this application are correct to the best of his/her <br /> knowlwcdge,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 hLAff 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 Joagian or any department,official or employee thereof;he shall <br /> defend,indenmify 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 tennis,conditions and restriction of this and any <br /> attached sheet,' as general o>r speCtial III . .ays. <br /> Signatrrre ofAppficant-Tine Date <br /> HELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««««««««««««««« <br /> i. DRIVEWAY: None �K Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat <br /> 3. PIPES: None K Existing-Type <br /> Othr pipes in Yes X No ❑ Approaches ❑ Cross Drain ❑ Size, <br /> Attac bment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No t9 �C Saafte� ho� �� Jn r Sito*< <br /> 5. ASPHALT CONCRETE DACE: Yes ❑ No ® S.aC¢ haus o� �jut <br /> 6. BARRIERS along Right-of--Way A44, <br /> 7. DITCH Yes R No ❑ Ifyes: "V'Style a. 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR �g COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth AC.over "Mia Depth 3/4"A.B. <br /> Notes <br /> L PIPES: Length of Pipe Required: Ft and Diameter a£Pipe Ines <br /> To be connected to a"adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No ER <br /> Total Length: (with proposed) Total Number of Storm Drain Inlet <br /> Notes 1. <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with "Mia Depth A.C.over "Mia 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 w10 pipe.............---.............................S95.00 ❑Paved frontage..................................$100.00+0.46/ft <br /> ❑ <br /> Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits0riveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />