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THE APPLICANT HEREBY CERTIFIES: <br />1. That helshe 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 v�ith all terms, condition and restriction <br />of this and any attached sheet, included as general or special III provisions. <br />A,�/ �; /% t// .. 7.- Zo 2 2 <br />Signature of Applicant Title Uate <br />»»»»»»»»»»»>»>»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />/ EXISTING CONDITIONS <br />1, DRIVEWAY: None e] Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ,' Flat ❑ <br />3. PIPES: NoneExisting —Type <br />Other pipes in neighborhood: Yes LJ No Ll Approaches Cross Drain Size <br />4. HEADWALL: Yes ❑<, NoA <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No,:;K <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No yJ if Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»>»»»»>»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z Commercial ❑ Agri <br />culture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over <9"Min Depth %" A.B. over <br />Notes: Nla4rA n3ct5flmc4 t!PrhCr4 WK 6 <br />2. PIPES: Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) <br />Notes: <br />Ft. and Diameter of Pipe / inch(es) <br />P <br />Total Number of Storm Drain Inlets: <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 $140.00 <br />Field Ins ection <br />Driveway w/orwlopipe <br />$140.00 a PavedFrontage $116.00+0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00+ 1.16/ff. <br />%'ENMOACHMMTDIM" WFun TenN1n ENCHWCHMENTPEHMR DNNEWAVE""RM) <br />