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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 />K #e - <br />Signature of Applicant Title Date <br />»»»»»»»»»»»»»»»>»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirl ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) �J Paved (good) ❑ <br />2. SLOPING: Away from Pavement �' Towards Pavement ❑ Flat ❑ <br />3. PIPES: None ❑ Existing—Type Co�tU i ib/lGte�t._— <br />Other pipes in neighborhood: Yes No U Approaches <br />4, HEADWALL: Yes ❑ No 14. <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No til <br />6. BARRIERS: <br />7. DITCH: <br />along Right-of-Wa <br />y <br />Yes No E]If Yes: V Style El <br />2 Point ❑ Other ❑ Width Depth <br />>»»»»»»>»>»»»»»>»»»>»>»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth %4" A.B. over <br />Notes: <br />2. PIPES: 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 />. .. / A i <br />Notes: <br />3. HEADWALL: Yes ❑ No �° <br />Ft. and Diameter of Pipe inches) <br />No <br />No <br />kNumer of Storm Drain Inlets: <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth''/4" 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/ or w/o <br />pipe $140.00 B Paved Frontage $116.00 + 0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00+ 1.16Ift. <br />K. NCRDACHMENTSWaft Fams PERM DRNEWAY.Ew(D ) <br />