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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 acwrdance with all terms, condition and restriction <br />of this and any attached sheet, included as general or special III provisions. N+^e Z <br />!_ <br />Mare", 2021 <br />Margot 6up t B@Plicant Title ate <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel � Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />mA <br />2. SLOPING: <br />Away from Pavement ❑ <br />None e <br />Other pipes i <br />4. HEADWALL: Yes ❑ N <br />Towards Pavement LJ Flat <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />along Right -of -Way <br />7. DITCH: <br />Yes E]Not If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial] Agriculture ❑ Industrial ❑ <br />Paved with 7i "Min Depth A.C. over &V57 "Min Depth''/." A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe /Y/ -H 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 />Notes: <br />3, HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth''YZ A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway w/or w/o pipe $140.00 Paved Frontoge $116.00+0.53/ft. <br />Driveway w/box Culvert $181.00 8 Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />PIHMOAGHMEM81M 1"FonnsTw&b GROACNMENF PEAMR ORrvEWAYdoo(") <br />