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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 any attached sheet,included as general or special III provisions, <br /> Signature of Applicant Tie ate <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: N�6 ne Ea Dirt ❑ Gravel 9° Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑`"Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑' Existing—Type <br /> e <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No n <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> i <br /> 6. BARRIERS: along Right-of-Way t t <br /> 7. DITCH: Yes ❑ No ®'If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [Commercial [7�Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth'/4'A.B.over <br /> Notes: /v t f <br /> �/ �c /fir")/.✓r � ,'°_f�:= r s , <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 0 <br /> Drainage Inlet Required Yes ElNo F-1Total Length: / (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No 0' <br /> 4. PAVED FRONTAGE: Paved with .'_ A "Min over Depth A.C. <br /> P "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 8 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIVEWAY.DOC (10109) Page 2of2 <br />