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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That heh� a has read all the provisions ofthis application,and that the description included in this application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That helsheis the owner of the respective property,or is qualified to represent the owned and <br /> 3. That helshe will assume full resperosibility for all liability for pe sonai 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 Sou Joagain or any department,official or employee thereof;he shall <br /> defend,indemnify and hold them and each ofthem 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 Encroec:bment Peru*and <br /> 6. Thaton is as requested,he agrees to do the work described in accordance with all teens,conditions and restriction oftbs and any <br /> general III provisions.r5 <br /> 1; re. 8 ►'j-o 4 <br /> Signature of Applicant-Tine Date <br /> FIELD INSPECTOR COAEURNTS <br /> »»»»»»»»»»»»»»»»»»»>>EXISTING'SSI TING CONDITIONS««r««««««««««««««««<<< <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑.. Paveci(pow) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No ❑ Approaches ❑ Cross Drain ❑ sme <br /> Attachment to neighbor's pipe: Yes ❑ No ❑ <br /> 4. HEADWALL: Yes ❑ No ❑ <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No ❑ <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No ❑ If Yes: V We ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PTPR& Length of Pipe Required: Ft.and Diamdw cf 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 Nurher of Storm Drdn Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No on <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min.Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$95.00 <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe...................................._.........$95.90 ❑Paved frontage........... .....................$100.00+0.46/ft <br /> ❑ Driveway w/bo,Culvert..:......................_.....................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98ht <br /> CounteslComputer,c:\AccesskApplicatiom for Pojrmrw\Dnveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />