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THE APPLICANT HEREBY CERTIFIES: <br /> that flue 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 application,and <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 grant as r uested,he agrees to do the work described in accordance with all terms,conditions and restriction of this and any <br /> attached sheet,included or special III provisions. �( 1211'a / <br /> Date <br /> Signature of Applicant-Title R Y <br /> FIELD INSPECTOR COMMENTS <br /> »»»»>»»»»»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««««««««««« <br /> ❑ Aggregate Base ❑ Paved(poor) ElPaved(Good) ❑ <br /> 1. DRIVEWAY: None g Dirt ❑ Gravel <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None 1W Existing-Type <br /> Other pipes in neighborhood: Yes El No ® Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No X <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No 1K If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»>»»>»»»»»»»»»»»»»»>PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR K 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: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No tZ <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Total Length: (with proposed) Total Number of Sturm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No RL <br /> 4. PAVED FRONTAGE: PAVED with "Min Depth A.C.over "Min.Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85.00 <br /> Field Inspection <br /> Paved frontag ..................................$100.00 0.46/ft <br /> ElDriveway w/or w/o pipe................................................$95. <br /> ❑ e + <br /> ❑ Driveway w/box Culvert......................I......I...................$155.00 ❑ Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Page 2 of 2 Revised 8/2000 <br /> Counter\Computer,c:\Access\Application for Pennits\Dnveway and Paved Frontage ag <br />