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R. <br /> THE APPLICANT HEREBY CERTIFIES:and 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 ofthis application, <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 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 department, �P Y <br /> defend,indemnify and hold them and each of them harmless for such claim;and -0f-Wa at the above indicated site <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Right y <br /> with a valid San Joaquin County Encmachment 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 /> attac d eet included as general or special III provisions. ,Z <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»>»»»»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««««<<<<<<« <br /> Gravel Aggregate Base ❑ Pavad(poor) ❑ Paved(Good) <br /> i. DRIVEWAY: None ❑ Dirt ❑ ❑ _pavement ❑ Flat ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards,,( <br /> 3. PIPES: None [I Existing-Type /2 �Y' <br /> Other pipes in neighborhood: <br /> Yes No ❑ Approaches ❑ Cuss Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes No ❑ <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DEKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH <br /> Yes EJ No ❑ If Yes: V Style 2 Point ElOther ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: <br /> FL.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No J4 <br /> Total Length: (with proposed) Total Number of Storm Dram Inlets <br /> Notes <br /> 3. HEADWALL Yes 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 /> Driveway Encroachment Permit base fee....................... ...$85. <br /> Field Inspection <br /> • .$95.00 ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/or w/o pipe............................................. .......$100.00+0.98/ft <br /> . El Curb,Gutter,Sidewalk................ <br /> El Driveway w/box Culvert................................................$155.00 <br /> Counter\Computer,c:\Access\Application for Permits\DrivewaY and Paved Frontage <br /> P 2 of 2 Revised 8/2000 <br />