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THE APPLICANT HEREBY CERINIES: on included in this application are correct to the best of his/her <br /> 1. That helshe has read all the provisions of this application,and that the description <br /> kmwlwdge,and <br /> 2. That helshe 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 Joaclam or any department, �P Y <br /> defend,indemnify and hold them and each of them harmless for such claire;and 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-of-Way <br /> with a valid San Joaquin County Encroachment Permit;and <br /> described in accordance with all terms,conditions and restriction of this and any <br /> 6. That if permission is granted as requested,he agrees to do the work <br /> attached sheet,included as general or special III provisions. / -7- <br /> 042 <br /> y <br /> Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»»»»»»»»»EXISTING CONDITIONS«««««««<<<<< ««««««« <br /> IF. DRIVEWAY: None E] Dirt F] Gravel Aggregate Base [IPaved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavement F1Towards Pavement E] Flat Q <br /> 3. PIPES: Norte ❑ Egg-Type <br /> Other pipes in neighborhood: <br /> Yes ❑ No ® Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4. WALL: Yes ❑ No 5 n <br /> S. ASPHALT CONCRETE DIKE: yes [I No � <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH <br /> Yes EJ No L9 If Yes: V Style El2 Po nt E] other <br /> F-1 Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> COMMERCIAL ❑ AGRICULTIM ❑ 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 /> Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No 14 <br /> ,rte Length. (with prod) Total Number of Storm Drabs Inlets <br /> Notes <br /> 3. HEADWALL Yes Efl No <br /> 4. PAVED FRONTAGE: PAVED with <br /> _"Min.Depth A.C.over "Min.Depth 314"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee...........................$85. <br /> Field Inspection <br /> . ❑ Paved frontage..................................$100.00+0.46/ft <br /> ❑ Driveway w/or w/o pipe........................................... ....$95. Curb,Gutter,Sidewalk......................$100.00+0.98/ft <br /> ❑ Driveway w/box Culvert...............................................$155.00 <br /> Countercomputer,c:lAccess\Application for Permits\Driveway and Paved Frontage <br /> Page 2 of 2 Revised 8/2000 <br />