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` T APPLICANT]HEREBY CERTIFIES: <br /> of flys lication,and that the description included m tbrs application are correct to the best of Mather <br /> g, That he/she has read all the provisions app° <br /> knowh*r,and <br /> or is ed to the owner;and <br /> 2, That he/she is the owner ofthe respective property, t <br /> 3. hat he/she will assume full responsibility for all tial�ity for personal injury or damage to property whichmay arse iout ofibe work described above, <br /> . or which may arise out ofbis/her failure to do the work provided herein;and shall . <br /> 4. That in the event any claim of suet liability is made against the County of SIM)Oagiun of any department,official or employee <br /> thereot he defend,indemnify and hold them and each of there 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 tame,conditions and restriction of this and any <br /> attached sheet, � general ctt spacial III Provisions. _ <br /> Signature of Applicwt-Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> EMSTING CONDITIONS««««««««<<<<< «««««« <br /> i. DRIVEWAY: None Dut ❑ Gravel ❑ Aggregate Base ❑ Pavel(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ® E -Type <br /> Other pipesin hid; Yes ❑ No Approaches ❑ Cross Drain ❑ Size C� <br /> Attachment to neighbors pipe: Yes ❑ No <br /> 4.XUDWALL: Yea ❑ No 5a <br /> 5. ASPHALT CONCRETE DUM: Yes ❑ No <br /> 6. BARRIERS along Rigbi-of W ay <br /> 7. DITCH Yes ❑ No 51 If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»>»»>»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRfCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min Depth 3/4"A.B. <br /> Notes <br /> L PIPES: Length of Pipe Reguirod: Fk and Diameter of Pipe _ Inc► <br /> To be connected to any adjacent driveway Pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length. (with proposed) Total Number of Storm Dram h filets <br /> Notes <br /> 3. HEADWALL Yes ® 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...........................$85. <br /> Field Inspection <br /> ❑ Driveway w/or w/o pipe........................................... ) ❑Paved$enrage............_._.................$100.00+0.46/ft <br /> ❑Driveway w/box Culvert.................................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Appticmtion for PermitslDriveway and Paved Frontage Page 2 of 2 Revised 8/2000 <br />