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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 />C9fxr� 1 <br />,\ (Z7 122 <br />�l �gnature of 4pplicant Title —bate <br />>»»»»»»»>»»>»»»»»»»>»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt aGravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ FlatA <br />3, PIPES: None ❑ Existing–Type 17-J/ RCP <br />Other pipes in neighborhood: Yes No Approaches Ll Cross Drain U Size <br />4, HEADWALL: Yes ❑ Nox <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No O <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes 0 No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>»»»»»»»»»»»»>»»»»>»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ,6 Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth %;' A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />2 ,e <br />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 umber of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No �] <br />4. PAVED FRONTAGE: Paved with <br />Measuring <br />Driveway Encroachment Permit base <br />Field Ins ection <br />Driveway wl or w/o <br />pipe $1 <br />Driveway w/box Culvert <br />XWNCRMCHMENTN 1W Fans -Tx kMAENCROACHMENI PERMIT DOWAY.Eoo(") <br />"Min <br />Depth A.C. <br />over <br />"Min Depth'/." A.B. <br />Feet <br />in length <br />and <br />Feet in width <br />Frontage <br />$116.00+0.53/ft. <br />ePaved <br />Curb, Gutter, Sidewalk <br />$140.00 <br />+ 1.16/ft. <br />