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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That hat4he has read all the provisions ofthis apPlica ion,and that the d=iption included in this application are correct to the best of him <br /> knowlwdge;and <br /> 2. Thst lielshe is the owner of the respective properly,or is gaalit3ed to resent the owner;and <br /> 3. That he/she will assume full responsibi far all labilq for pasoml ujmy or damage to property which may arise out ofthe work described at <br /> or which may arise out of W-Aw failure to do the wank pmvidedherein;and <br /> 4. That in the event any claim of such liability is made against the County of San Joaqimi or any depahrtment,official or employee thea eog he shall <br /> defend,indemnify and hold them and each of them hamileas for each clam 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 Encroac hsne t Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all tears,conditions and restriction of this and any <br /> attached sheet,included as genaii or special IH provisions. <br /> Signture ofApplicra-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS««-�«««««««««««««««« <br /> 1. DRIVEWAY: None <br /> i ❑ Dirt 54 Gravel ❑ Aggtegate Base ❑ Paved(poor) ❑ Pavod(Goo <br /> 2 SLOPING: Away from Pavement ❑ Towards Pavement Flat ❑ <br /> 3. PIPES: None ❑ Existing-Type N� <br /> { OthwP Yes No ❑ A ❑ Cross Drain ❑ Size <br /> Attschmea>t to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No 0+ <br /> S. ASPHALT CONCRETE DIKE: Yes C9 No El <br /> 6. BARRMS along Right-of-Way <br /> 7. DITCH Yes ❑ No ❑ If Yes: V Style J4 2 Point ❑ Odw ❑ Width Depth <br /> i »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««« <br /> a 1.DRIVEWAY: SFR ❑ COMMERCIAL ❑ AGRiCULTFJRE INDUSTRIAL L] <br /> 1 PAVED with "Min Depth A.C.over "Min.Depth 3/4"A B <br /> ;i Notes <br /> 2 P11PE6 Length of Pipe Required Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway Pipe Yes ❑ No 24 <br /> DRAINAGE INLET REQUIRED Yes ❑ No P9 <br /> T (with proposed) Total Number of Storm Dann Tellers <br /> i <br /> Notes <br /> t <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Min.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Mpg Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee........................ ..$85.00 <br /> Field Inspection <br /> El Driveway w/or w/o pipe.............._............................ ..$95.00 ElPaved frontage................................$190:00+0.46/ft <br /> ElDrivewayw/boxCalvert..:......._....................................$1 00 <br /> ❑Curb,Gutter,Sidewalk......................5100.00+0.98/ft <br /> CounterlComputer,c:�AccesslApplication for Peamits\Dnveway and Paved Frontage Page 2 of 2 Rc <br /> e <br />