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THE APPLICANT HEREBY CERTIFIES: ,�1 in this application are correct to the best of his/her <br /> 1. That he/�lte has read all the provisions ofthis appheatian,and hat the description <br /> $nowlwdge;and <br /> 2. That he/she is the owner of the respective properly,or is qualified to represent the owner and <br /> 3.That he/she will assume full responsibility for all liability for personal iqy or damage to property which may arise out of the work described above, <br /> or which may arm 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 Sae Joaquin 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 agrees to do the work described in accordance with alt terns,conditions sed restriction ofthis and any <br /> attached Ch! er�--M visions. <br /> fYi/ <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »>EMTING CONDITIONS««<«««««««««««««««««< <br /> L DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Pav*Good) ❑ <br /> 2. SLOPING: Away firm Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing-Type <br /> other pipes in neighborhood: Yes 50 No ❑ Approaches ❑ Cross Drain ❑ Size C� <br /> Aunt to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No 19 <br /> C. BARRIERS along Rig) -of-Way <br /> 7. DITCH Yes ❑ No ❑ If Yes: V Style X 2 Point ❑ Other ❑ Width <br /> Dopth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR �Q COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: <br /> Of Pipe R-Pined: Ft.and Diameter of Pipe Inch <br /> To be connected to any a4acent driveway pipe Yes ❑ No [9 <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <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. <br /> Field Inspection <br /> ElDriveway w/or w/o pipe........................................... 2 El PnvedEros►lege.........,.. ...._..............$I(i0.00+0.46/ft <br /> ❑ Driveway w/box Culvert_.............................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Permits\D riveway and Paved Frontage <br />