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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 properly 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 of any department, official or employee <br />thereof, he shall defend, indemntly 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_anytattached sheet, included a genera 6 special III provisions. <br />I 14g <br />Signature of Applicant Title Dateff <br />v <br />»»>»»»»»>>»»»>»»»»>»»»»FIELD INSPECTION (OFFICE USE ONLY)<««««««««««««««««««< <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ,� Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: <br />3. PIPES: <br />4. HEADWALL: <br />Away from Pavement <br />None <br />Other i es i <br />Yes ❑ N <br />Towards Pavement Li Flat1y <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No 1W <br />If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>>>>>>>»»»»»»>» »»»»» >>>»»»»»»>PERMITS REQUIREM€NTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture, Industrial ❑ <br />Paved with "Min Depth A.C. over. "Min Depth'/," A.B. over n <br />Notes: <br />2. PIPES: <br />Notes: <br />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 />3. HEADWALL: Yes ❑ No �— <br />No <br />No <br />Total Number of Storm Drain Inlets: <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth'/:' A.B. <br />Measuring Feel in length and Feet in width <br />»»>» » >»»»»»»»>>>>»»>»»»»»>»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 �e i <br />Field In ection <br />Driveway wt or w/o pipe $140.00 B Paved Frontage $116.00 + 0.531ft. <br />Driveway w/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />F1EIIt0.0ACnME11i5Wr:m fannlu,µ"w�LI,CHGgL,UlfNl fEW11f IMIKWAY ac 1�1 <br />