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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 andany atta d sheet,includ as general or special III provisions. <br /> �Applic Uate <br /> >»»»»»»»»»»»»»»»»»»»»»FIE EXISTING INSPECTION <br /> CON COI MENTS«««««««««««««««««««««< <br /> NS <br /> 1. DRIVEWAY: None [Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat [R--_(�5hou/dlpr <br /> 3. PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No Ee <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No []� <br /> 6. BARRIERS: along Right-of-Way 1,1.0h e__ <br /> r 7 <br /> 7. DITCH: Yes Ee�"`No ❑ If Yes: V Style 2 Point ❑ Other ❑ Width �_ Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREM ENT S««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial Agriculture ❑ Industrial ❑ <br /> P// �Y/ <br /> a►►ved with �i "Min Depth A.C.over //�O "Min Depth%"A.B.over / <br /> Notes: COr/fo/ w �'/� $•.�. Ca . /� r, Ste. A!J (SPS 4/iG/GNPa�I inClU�h /tT��h <br /> `aa�ii �o aeeorfiod�Tevexien7s <br /> 2. PIPES: Length of Pipe Required <br /> Q Ft,and Diameter of Pipe /8 1141h ' inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No 5K <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: / /— 1(with proposed) Total Number <br /> of Storm Drain Inlets: <br /> Notes: � Pi t /Py ��/ 4� 2N4�'srT dh 4r%�eluo Gvio7`�l AhU l'oH�i.>�ih G� /P.=17 <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth 1/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee_�,__$125.00 <br /> Field Inspection H <br /> Paved Frontage $116.00+0.53/ft. <br /> Driveway w/or w/o pipe $110.00 Curb,Gutter,Sidewalk$ 113.00+ 1.08/ft. <br /> Driveway w/box Culvert $179.00 <br /> 11SJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT DRIVEWAY.DOC (10109) Page 2of2 <br />