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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 attached sheet,included as general or special III provisions. /4— <br /> F��^^ �urof Date <br /> �Sign pp n Title v <br /> »»»»»»»»»»»»»»»»»»»»»>FIE EXISTING INSPECTION <br /> CON ITOMMENTS«««««««««««««««««««««< <br /> IONS <br /> 1. DRIVEWAY: None [D-/' <br /> Dirt ❑ ,—G,ravel E] Aggregate Base ❑ Paved(poor) ❑ Paved(good) El2. SLOPING: Away from Pavement 52rTowards Pavement EJ Flat ❑ <br /> 3. PIPES: None [�" Existing–Type /V//7 <br /> Other pipes in neighborhood: Yes No Approaches 0 Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No [K <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No /[ <br /> 6. BARRIERS: along Right-of-Way �`�"'� <br /> 7. DITCH: Yes ❑ No 0 If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial El <br /> Paved with / v "Min Depth A.C,over }/ 7 ")Min Depth%"A.B.over <br /> �7 i �d i iry� G✓i�/`) �.� l-G ���r ��" rJ C`�. �i.�E, /� `��� <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> /4- Ft.and Diameter of Pipe d//q inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No [D'' _____ <br /> Total Length: `– (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with f" "Min Depth A.C.over "Min Depth 3/<"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Ins ection Paved Frontage $116.00+0.53/ft. <br /> riveway w/or w/o pipe $110.00 ❑ Curb,Gutter,Sidewalk $113.00+ 1.08/ft. <br /> Driveway w/box Culvert $179.00 <br /> 11SJPWGOV.ORGISHARESICENTRALSERVICES\CLERICAL\PUB-SV.WKIMASTER.PS\ENCROACHMENT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br /> i <br />