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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 in this application are correct to the best of his/her <br /> ktmwlwdge,and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owned and <br /> 3. That he/she will assume e full responsibility for all liability for personal injury or <br /> damage to property vvhida 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 San Joaginn 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 temps,conditions and restriction of this and any <br /> attached sheet,included as general or special III provisions. <br /> Signature of Applicarn-Title D <br /> ate <br /> FIELD INSPECTOR COMMENTS <br /> »»»»>EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None [ Dut ❑ +Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None 54- Existing-Type <br /> Odder pipes in neighborhood:- Yes ❑ No Approaches ❑ Cross Drain ❑ Size C� <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No (?- <br /> * ASPHALT CONCRETE DIICE: Yes ❑ No <br /> 6. BARRIERS along Riglt-of-Way <br /> 7. DITCH Yes ElNo �A- If Yes: V Style Z point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR A COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> E. PIPES: Length of Pipe Required: It and Diameter of pipe Inch <br /> To be conceded to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storer Drat Inlets <br /> Notes <br /> F- <br /> 3. HEADWALL Yes ® No { <br /> 4. PAVED FRONTAGE: PAVED with T' "Mia.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.......................................... ....$95.00 ❑Paved ..... <br /> fiontage.................., $100.00+0.46/ft <br /> El Driveway w/box Culvert................................................$155.00 ❑Curb,Gutter,Sidewalk.................. $100.00+0.98/ft <br /> Coucter\Cornputer,c:\Access\Apphcation for Pemuts\Driveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />