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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 ny att ched_ sheet,incl u d as general or special III provisions. <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>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 2""'Existing—Type �1A <br /> Other pipes in neighborhood: Yes LJ No Z Approaches L Cross Drain L Size <br /> 4. HEADWALL: Yes ❑ No 19-11- <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way G�dn e <br /> 7. DITCH: Yes ❑ No N f YYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with 7i "Min Depth A.C.over "Min Depth%"A.B.over <br /> Notes: &9n1o'ern Wi h 51 • eo . �ia- . S� ,Ow%. l✓o . 2�/� <br /> 2. PIPES: Length of Pipe RequiredN�,4 Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No EPI- <br /> Drainage <br /> tomDrainage Inlet Required Yes ❑ No 0-� <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: _ <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No L�' <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 $125.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe $110.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 B Curb,Gutter, Sidewalk $113.00+ 1.08/ft. <br /> IMPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10/09) Page 2 of 2 <br />