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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 permi siofi i granted as requested, agrees to do the work described in accordance with a I terms,condition and restriction <br /> of this a ny ch d sheet,included eneral or special III provisions. <br /> ` Sigature of 40plicaWritle DbtEr <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 [►]Existing—Type <br /> Other pipes in neighborhood: Yes No - Approaches Cross Drain LJ ize <br /> 4. HEADWALL: Yes ❑ No Uj,*'— <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No f[� <br /> 6. BARRIERS: along Right-of-Way /�(G�4 <br /> 7. DITCH: Yes ❑ No Ej� 1f Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREM ENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture ❑ Industrial <br /> /tPaved with "Min Min Depth A.C. <br /> -% <br /> over "Min Depth "A.B.over <br /> Notes �'ah /,� tv�j�-/7 /,OV�0/, JAI QWg`,/'/0 ae diiaeway A ddAih �wdy �d�Yh YoOc�kJay� <br /> Aloiltale Ye km 11ddi/ 0CCOAMC%a� fi't/C,�_ �u�s�:r�7 /jeilel-ie'_1 � <br /> 2. PIPES: Length of Pipe Required - Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [ <br /> Drainage Inlet Required Yes ❑ No E] <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No 02--" ,/ <br /> 4. PAVED FRONTAGE: Paved with N�� "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 /> IISJPWG0V.0RGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT DRIVEWAY.DOC (10/09) Page 2of2 <br />