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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 "I quested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any aft ted sheet, in •lu:led as general or special III provisions. <br />Z'1lr1h22— <br />ature of Applicant Title I Uate <br />»»»»»>»»»>m»»>»»>»»»>»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <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 <br />Other p as in neighborhood: Yes No Approaches Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No t <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No k If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»»»»>»»»»»»»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR 0 Commercial ❑ Agriculture ❑ Industr�iyal F] <br />Paved with 2 "Min Depth A.C. over i "Min Depth Y4" A.B. over <br />Notes: 454157;016 7>A/ AyoA6 !MeN /.5 $ElAJ(5 d&0oJEZ) ;qQ f1 W1e-A0r% <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 />Notes: <br />Ft. and Diameter of Pipe N/ <br />No <br />No <br />Total Number of Storm Drain Inlets: <br />inches) <br />3. HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth Y4" A.B. <br />Measuring Feet in length and Feet in width <br />»»»»>»»»»»»»»»»»»»>»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Dri <br />veway Encroachment Permit base fee $140.00 \ yq� � <br />Fie d Ins ection I <br />Driveway w/ or w/o pipe (x?) $140.00 220. °' e Paved Frontage $116.00 + 0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.161% <br />X^ENCROACHMF311Skaslar FamwTw,WalesIENCROACHMENi PERMR ORNEWAY4w (08tlB) <br />