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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 <br /> /sheet,included as general or special III provisions. <br /> J� Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»>»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> 49ticu/7 uv� Al sid 4�u/ EXISTING CONDITIONS <br /> 1. DRIVEWAY: one [9' Dirt ❑ Gravel [ErAggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavemen Towards Pavement [Flat ❑ <br /> 3. PIPES: None 2'Existing–Type <br /> Other pipes in neighborhood. Yes No LJ Approaches LJ Cross Drain Size___LZ:z" <br /> 4. HEADWALL: Yes ❑ No 2" <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> [ <br /> 6. BARRIERS: along Right-of-Way <br /> 7. nom. Yggs � No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> Sh�Il�ac Sc�q l e— <br /> >»»»»>»»»»»»»»»»»»»>»>»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR 2"' Commercial El Agriculture Industrial ❑ <br /> Paved with Z %4 <br /> "Min Depth A.C.over "Min Depth "A.B.over Z °``'� `� ' <br /> Notes: ` �v�I4ow/'1-/7 5'„!.Co. hwr. Sid. p <br /> fl10,ll j��'�r�gl✓I <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 M"– <br /> Drainage Inlet Required Yes ❑ No E4-- <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No 0/ <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth Y4"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 /> TT—Ddveway w/or w/o pipe $121.00 ® Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $181.00 Curb,Gutter,Sidewalk $121.00+1.16/ft. <br /> M:{CEN RALSERVICES4CLERICALIPU&SV.WKVu1ASTER.PSIENCROACHMENTPERMfTDRNEWAY.DOC (09113) Page 2M2 <br />