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THE APPLICANT HEREBY CERTIFIES: <br /> L 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 /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to property which 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 Joaqiun 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 terms,conditions and restriction of this and any <br /> attached sheet,included as general or III ro <br /> Signature ofApph ..__..T e <br /> Date <br /> FIELD INSPECTOR COAIWNTS <br /> FSLOPING. <br /> »»>»»»»»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««««««««««« <br /> I. Y: None � Dirt ❑ Gravel <br /> ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> Away from.Pavement Towards Pavement <br /> None Flat ❑ <br /> Existing-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cross <br /> amain ❑ Size <br /> Attachment to neighbor's pipe: Yes ED No <br /> 4. HEADWALL: Yes ❑ No R <br /> S. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No 1�5 If Yes: Ve <br /> Sty! ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS««««<<<<< «««««««««« <br /> 1. DRIVEWAY: SFR R COMMERCIAL ❑ AGRtCULTURE <br /> ❑ INDUSTRIAL ❑ <br /> PAVED with <br /> Notes "Min.Depth AC.over "Min Depth 3/4"AB. <br /> 2. PIPES: Length of Pipe Required: <br /> Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No ® --_ <br /> DRAINAGE INLET REQUIRED Yes ❑ No &? <br /> Notes Total Length: (with proposed) Total Nmnber of Storm Drahu Inlets <br /> F- <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with <br /> "Min-Depth A.C.over �,Min Depth 3/4"AB. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> 71nspection <br /> ent Permit base fee......................... .$SS.o <br /> /o pipe................................................ 95.0 <br /> ❑Paved froutage..................................$100.00+0.46/ft <br /> yoxCulvert.................................................$155.00 <br /> ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for Permits\Driveway and Paved Frontage Page 2 of 2 <br /> Revised 8/2000 <br />