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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 r special III provisions, <br />Signature of Applicant Title 1100F Date <br />»»»>»»»>>»»>» »»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None 0 Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement 1 ] Towards Pavement ❑ Flat ❑ <br />3. PIPES: None 9 Existing–Type r <br />Other pipes in neighborhood: Yes It No LJ Approaches a Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No A <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No 9 <br />6. BARRIERS: <br />7. DITCH: <br />along Right -of -Way <br />Yes IBJ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />>>>»»»»>>>>»»>>>>»»»»>»»»»» »»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR it. Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over 4— "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />3. HEADWALL: Yes ❑ No <br />Ft. and Diameter of Pipe inch(es) <br />No <br />No <br />Total Number of Storm Drain Inlets: <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 $140,00eq `o <br />Field Ins ection // <br />Driveway w/ or w/o pipe $140.00///r a Paved Frontage $116.00 + 0.53/ft. <br />Driveway w/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00 +1.16/ft, <br />XQ1MWHMWMftW F—Te"pb"ENCRCCH tff POW CWMAY da(WM) <br />