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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 />U. That if permission is granted as requested, he agrees to do the work described in accordance with all terms, condition and reslridion <br />of this and any attached sheet, included as general or special III provisions. <br />p,��5, 4(-+ a'/,)(/ ZoZZ <br />Signature of Applicant Title Date <br />»»>»»»»»>>>>»»»»»>»»>>>>>>>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 [A Existing—Type <br />Other pipes in neighborhood: Yes No Approaches Ll Cross Drain L Size <br />4. HEADWALL: Yes ❑ No C✓� <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No [JJ <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No [Z If Yes: VStyle ❑ 2Point ❑ Other ❑ Width Depth <br />»»»>»»»»»»»»»>» »»»>»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR d Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over 4 "Min Depth'/." A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />Ft. and Diameter of Pipe N A inches) <br />To be connected to any adjacent driveway pipe Yes ❑ No [✓ <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) 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 />»»»»»»>»»»»»»»>»»'>>>>»»»»»>»»»> F E E S ««««««««««««««««««««««««««« <br />Dri <br />veway Encroachment Permit base tee $140.00 <br />Field Ins ection <br />Driveway wl or wlo pipe $140.00 B Paved Frontage $116.00 + 0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />X,E WA01Mf1TSNhsb, Fw Te" WWS%MOAWNF1trPFNAt WP AY.° (") <br />