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THE APPLICANT HEREBY CERTIFIES: <br /> 1. 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 <br /> his/her knowledge;:and <br /> 2. That he/she is the owner of the respective property,or qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> described above,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 Joaquin or any department,official or employee <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall /performeda applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated W ` uin County Encroachment Permit;and <br /> 6. That if rmissi uested,he agrees to do the work described in accordance with all terms,condition and<restriction <br /> of this n a auded as general or special III provisions. <br /> gnature of Applicant Title Date. <br /> »»y»»»»»»> »»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt Gravel ❑ Aggregate Base.❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement [ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None &K Existing—Type <br /> Other pipes in neighborhood; Yes No Approaches U Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No [ ' <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way ' <br /> 7. DITCH: Yes ❑ No [91fYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»>>»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture Industrial ❑ <br /> Paved with "Min Depth A.C.over " "Min Depth 1/4"A.B.over <br /> Notes: 4 4 1? <br /> ,? rr", <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe "`� inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No ER''. <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: - <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "' "Min Depth A.C.over "Min Depth'/<"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee_�$85 88 <br /> Field Ins ection <br /> Driveway w/or w/o pipe .$96.80' ❑ Paved Frontage $100.00+0.46/ft. <br /> Driveway w/box Culvert $155.00 Curb,Gutter,Sidewalk $100.00+0.98/ft. <br /> M:ICENTRALSERVICES\CLERICALIPU&SV.WKIMASTER.PS\ENCROACHWENT PERMT DRIVEWAY.DOC (01=) Page 2 W 2 <br />