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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/ r-e representative of the application in the County Right-of-Way at the above <br /> indicated site with a vali Joaquin Coun ncro ment Permit;and <br /> 6. That if permissio nted as re ruyefi to do th?,work described in accordance with all terms,condition and restriction <br /> of this and a a ed sheet,jn a gener or�spe aci'I III provisions. <br /> Signature of Applicant Title D to <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel 2111'Aggregate Base ❑ Paved(poor) 0`"Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat [� <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in neighborhood: Yes No LJ Approaches LJ Cross Drain LJ Size <br /> 4. HEADWALL: Yes ❑ No ©-1- <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way j"kilt <br /> 7. DITCH: Yes No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width ` Depth -'> <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture [Industrial ❑ <br /> Paved with 2 "Min Depth A.C.over "Min Depth%"A.B.over <br /> Notes: ��h c,%v, 4-1:5'J 6, �hiw. �� �G��� . /�lo: /7 �i w<���4' A, 4uvf� <br /> 2. PIPES: Length of Pipe Required ( 'J Ft.and Diameter of Pipe inches) <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: lJ S��Gj i9�7 �t'//j/l '0Igiij e,ev/N����i�>���<<U <br /> 47 e i,41 J. <br /> 3. HEADWALL: Yes ❑ No [D/ <br /> 4. PAVED FRONTAGE: Paved with A� 14 "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 Ins ection <br /> Driveway w/or w/o pipe $110.00 ❑ Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 Curb, Gutter, Sidewalk $113.00+ 1.08/ft. <br /> 11SJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br />