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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, agrees to do the work described in accordance ith all terms, condition and restriction <br />of this and any att he sh et, ME=` <br />eneral or ecial III provisions. <br />�, ,// /6 ?, <br />Signature of Applicant Title )gate <br />»»»»»»»»»»»>»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />/ EXISTING CONDITIONS <br />1. DRIVEWAY: None E] Dirt ❑ Gravel © Aggregate Base ❑ Pave (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from <br />Pavement E]Towards Pavement ❑ Flat <br />3. PIPES: None 2 Existing — Type <br />Other pipes in neeiighhborhood: Yes No Approaches Cross Drain Size <br />4. HEADWALL: Yes E]No E <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No E <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No 2 If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»>»»>»»»»»»>»>»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over t <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />"Min Depth'/." A.B. over <br />Ft. and Diameter of Pipe <br />To be connected to any adjacent <br />driveway pipe Yes ❑ <br />No <br />❑ <br />Drainage Inlet Required <br />Yes ❑ <br />No <br />❑ <br />Total Length: <br />(with proposed) <br />Total <br />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''/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 pipe $140.00 a Paved Frontage $115.00 + 0.53/ft. <br />Driveway w/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />XG NCRDAWWNT@M Fm iar WnWNCRMCHN WPBW DWWW(") <br />