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THE ApPLICANT HEREBY CERTURScm this application are correct to the best of h'lher <br /> 1. That helshe has read all the provisions of this apPltcahan,and that the description included <br /> Imowlwdge;and the owner,and <br /> of the respective property,or is qualified to represent bad above, <br /> 2. That heJshe is the owner or damage to property which may arise Dirt of the work described <br /> 3. That helshe will assume fuU responsrbdrty for all liability far p�injuryand <br /> n <br /> or which may arise out of his/her failure to do the work provided herein; arf»>ant,official or employee thereof he shall <br /> 4. That in the event any claim of such liability is made against the County <br /> of San Joagiun or any dep <br /> and hold and each of them harmless for such claim;and site <br /> defend,irrdemntfY d them ve of he applicant in the County Right4f Way at the above indicated <br /> 5. That work shall be performed by the applic a t and/or any repraseatnt+ <br /> with a valid San Joaquin County Encraacbment Permit;andconditions and restriction of this and any <br /> 6. That if permission is granted as requested,he ago'to do the work described in accordance with all teams, <br /> attached sheet,included as general or special III provisions' <br /> Date <br /> Signature of Applicant Title <br /> FIELD INSPECTOR COMMENTS <br /> EX BTING CONDITIONS«««««««««««<<<<<<««« <br /> Paved poor) ❑ Paved(Good) ❑ <br /> None [] Dirt ❑ Gravel ® Atte Base ❑ <br /> 1. DRIVEWAY: C] <br /> Away from Pavement <br /> ❑ Towards Pavement ❑ F <br /> 2. SLOPING: <br /> 3. PIPES: None ❑ Exutin8-Type (] Cross Drain ❑ S¢e E <br /> Other pipes in neighborhood: Yes ❑ No ® Approaches <br /> Attachment to neighbor's pipe: <br /> Yes U No LA <br /> 4. HFADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DIKE: <br /> Yea ❑ No <br /> 6. BARRIERS alongRrght-of-Way Other ❑ - <br /> 7. DITCH Yes ❑ No If Yea: V Style ❑ <br /> 2 Point ❑ Width Depth ---- <br /> »»»»»»»»»»»»,,>»»»»»»»PERMIT REQUIREMENTSAGRICULTURE ❑ INDUSTRIAL. ❑ <br /> 1. DRIVEWAY: SFR � COMMERCIAL ❑ <br /> » <br /> PAVED with Min.Depth AC.over "Min.Depth 3/4"AB_ <br /> _._ <br /> Notes <br /> Ft and DiamdOr of P'pe Inch1. YIPE&. Lzngth of Pipe Required: <br /> To be connected to any adjacent driveway pipe <br /> Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> (�propO8ed) Total Nmnber of Storm Dr'adn Itsnle ^ , <br /> Total Length: �_ <br /> Notes _ J <br /> 3. HEADWALL Yes 0 No ® „Min.Day 3/4"AB. <br /> PAVED with "Min_Depth A.C.over �„_ <br /> 4. PAVED FRONTAGE: -------- Feet in width <br /> Measuring Feet in length and <br /> FEES <br /> Driveway Encroachment Permit base foe...........................$85. <br /> Field Inspection �ed frontage..................................$100.00+0.46/ft <br /> $95. <br /> ❑ Driveway w/or w/o pipe......................... b,Gutter,Sidewalk......................$100.00+0.981ft <br /> .................. <br /> .........$155.00 <br /> ❑ Driveway w/box Cu vert.................... Page 2 of 2 Revised 812000 <br /> Courrter\Computu,0Access\App <br /> Iication for Permits\Dnveway and Paved Frontage <br />