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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has read all the provisions of this application,and that the description included in this app <br /> knowlwdge;and )ion are correct to the best of his/her <br /> 2. That he/she is the owner of the respective property,oris qualified to represent the owner,and <br /> 3. That helshe will assume full responsibility for all liability for personal injury or damage <br /> or which may arise out ofhis/her failure to do the work provided herein and to property which may arise out of the work described above, <br /> 4. That in the event any claim of such liability is made against the County of San Jo iun or as <br /> defend,indemnify and hold them and each of them Y department official ar employee thereof be shall <br /> harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the C <br /> with a valid San Joaquin County Encroachment Permit; ounty Right-of-Way at the above indicated site <br /> County and <br /> 6. That ifpennission is gamed as requested,he <br /> attached shee Fees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> t ded as genera!or ia!III ovisions. <br /> X <br /> Signature of Applicant-Title <br /> Date <br /> »»»»»»»»»»»»»»»»»»>FIELD INSPECTOR COMMENTS <br /> EXISTING CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: None ® Dirt <br /> ❑ Gravel [] Aggregate Base ❑ <br /> 2. SLOPING: Away fromPaved(poor)pavement ❑ Paved(Good) ❑ <br /> ❑ Towards Pavement <br /> Flat <br /> 3. PIPES: None <br /> Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No <br /> Approaches ❑ Cross Drain El Size <br /> Auachmeltt to neighbor's pipe: Yes El No <br /> 4. HEADWALL: Yes [I No <br /> S. ASPHALT CONCRETE DUM: <br /> Yes ❑ No LR <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No <br /> © If Yes: V Style ❑ 2 Point [] Other Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT ❑ Width <br /> 1. DRIVEWAY: SIR <br /> «««««««««««««««««««« <br /> SFR ® COMMERCIAL ❑ AGRICULTURE <br /> PAVED with El INDUSTRIAL E]"Mi <br /> n.Depth AC.over <br /> Notes �I Mm.Depth 3/4"AB. <br /> 2, PIPES: Length of Pipe Required: <br /> _Ft.and Diameter of Pipe Inch <br /> To be corrected to any adjacent driveway pipe Yes �-- <br /> ❑ No <br /> DRAINAGE INLET REQUIRED Yes <br /> ❑ No <br /> Total Length: <br /> Notes ----(with prod) Total Number of Storm Dram Inlets <br /> 3. HEADWALL Yes No ER <br /> 4. PAVED FRONTAGE: PAVED with <br /> Min.Depth AC.over <br /> Measuring --- Min.Depth 3/4"AB. <br /> Feet in length and Feet in width <br /> Driveway Encroachment Permit base fee........................ ..$85.00 FEES <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe................................................$95.00 <br /> ❑Paved froutage..................................$100.00+0.46/ft <br /> Driveway w/box Culvert........ <br /> $155.00 <br /> ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\AccesslApplication for Permits\Dnveway and Paved Frontage Pa of 2 <br /> Revised 8/2000 <br />