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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 is 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 be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site 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,condition and restriction <br /> of this and any attac d sheet,included as general or special III provisions. <br /> Signature Applicant TitleTitle Z– <br /> _ s�f e 9 ate <br /> »»»»»»»»»>s�>»»»»»->»»FIELD INSPECTIOfVCOM ENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ®` Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement M'' Flat ❑ <br /> 3. PIPES: None ❑ Existing–Type <br /> Other pipes in neighborhood: Yes LJ No Approaches 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 ©If Yes: )/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'/,"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required — f <br /> Ft.and Diameter of Pipe ,c inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> r r <br /> r <br /> 3. HEADWALL: Yes ❑ No <br /> 1 <br /> 4. PAVED FRONTAGE: Paved with <br /> "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 $125.00 S <br /> ?!Driveway <br /> Ins ection 23 <br /> Driveway w/or w/o Pipe ;6110.0 Paved Frontage <br /> w/box Culvert $179.00 $116.00+0.53/ft. <br /> Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> %%S.IPWGOV.ORG%SHARESICENTRALSERVICESICLERICALIPU&SV.WK%WTI:R.PSIENCROACHMENTPERMITDRIVEWAY.DOC (1x09) Page 2 of 2 <br />