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THE APPLICANT HEREBY CERTIFIES: A <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 permissi is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this d a achedMUricluded as general or special III provisions. <br /> t 4 �-- <br /> Sign ture of pplicant Ti a ate <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 [t�Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches 0 Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No E <br /> 6. BARRIERS: along Right-of-Way do n <br /> 7. DITCH: Yes Eg" No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width G Depth <br /> »»»»»»»»»>i»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with -'2, "Min Depth A.C.over "Min Depth%4"A.B.over <br /> Notes: 't ILII2-/7 TV. K). A, r s�/. �Ll✓�, �/u <br /> t <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe 12, � AP 4 inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No M <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: A/1/1 <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <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 $135.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe $121.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $181.00 B Curb,Gutter,Sidewalk $121.00+1.16/ft. <br /> M.ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIVEWAY.DOC (09113) Page 2of2 <br />