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THE APPLICANT HEREBY CERTHUS: that the description included in this application are correct to the best of his/her <br /> 1. That he/she has read all the provisions of this app <br /> lication,and knowlwdge;and <br /> 2. That he/she is the owner of the respective properly,or is qualified to represent the owner,and <br /> responsibility f <br /> 3. That he/she will assume full or 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 artmeM official or employee thereof he shall <br /> 4 That in the event any claim of such liability is made against the County of San Joaqiun or any . <br /> defend,indemnify <br /> and hold them and each of them harmless for such claim;and <br /> Ove of the <br /> applicant in the County Right-of-Way at the above indicated site <br /> 5. That work shall be performed by the applicant and/or any represents <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,in uded as gen 0 ec' provisions. X 2 © �, <br /> ate <br /> x Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDMONS««««««««««««««7Pavd(Good) 0 <br /> e Base ❑ Paved(poor) ❑WAY: None [ Dut ❑ Gravel ❑ �t'x1. DRIVE Flat ❑2. SLOPING: Amvay from PavementTwds Pavement ❑Existing-Type3. PIPES: None oahes ❑ Cross Drain ❑ <br /> Other pipes in neighborhood: Yes ❑ No APpr <br /> Attachment to neighbor's pipe: <br /> Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No �- <br /> 5. ASPHALT CONCRETE DI": Yes ❑ No <br /> 6. BARRIERS alongRmght-of-Way Other 11Width — <br /> 7. DITCH Yes ❑ No If Yes: V Style ❑ 2 Point LJ <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL El <br /> PAVED with <br /> Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> J Ft.and Diam ew of Pipe Inch <br /> 2. PIPES <br /> To <br /> of Pipe Required: �_ — �— <br /> adjacent driveway pipe Yes El No To be connected to any <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> (with proposed) Total Number of Storm Drain Inlets <br /> Total Length: <br /> Notes <br /> 3. HEADWALL Yes ❑ No <br /> Min.Depth A.C.over "Mian.Depth 3/4"A.B. <br /> 4. PAVED FRONTAGE: PAVED with .11 <br /> in <br /> Feet in length and Feet in width <br /> Measur•irrg --� <br /> FEES <br /> Driveway Encroachment Permit base fee........................ ..$85.00 <br /> Field Inspection Paved frontage $100.00+746/8ft <br /> �$9 .00 ❑ g ................................. <br /> ❑ Driveway w/or w/o pipe.............................................. 00 <br /> ❑ Curb,Gutter,Sidewalk......................$100.00 <br /> Driveway w/box Cu vert..•••••........•..••• Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Pemmits\Driveway and Paved Frontage <br />