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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 requested,he agrees to do the work described in accordance with all ,condition and restriction <br /> of this and any attach d as general or special III provisions. <br /> ��L/7,/ <br /> or Signature kWplicant Title Daw <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 IVIA <br /> Other pipes in neighborhood: Yes LJ No Approaches H Cross Drain 0 Size <br /> 4. HEADWALL: Yes ❑ No ®� <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way done- <br /> 7. DITCH: Yes ❑ No f Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial <br /> �t Paved with Z ,J <br /> "Min Depth A.C.over 7 "Min Y. <br /> /Depth "A.B.over <br /> Notes: `G'lv '� ��—/ .�,�4�, ket, sa, <br /> 2. PIPES: Length of Pipe Required d A Ft.and Diameter of Pipe /� inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [ F <br /> 4. PAVED FRONTAGE: Paved with �`f "Min Depth A.C.over "Min Depth1/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $135.00 <br /> Field Inspection,Er <br /> Driveway w/or w/o pipe $121.00 ����' Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $181.00 H Curb,Gutter,Sidewalk $121.00+1.16/ft. <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKVMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (09/13) Page 2 of 2 <br />