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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 Joaq in County Encroachment Permit; and <br />6. That if permission is grant as r uested, he agrees to do the work described in accorda ce wi72�0 <br />all terms, condition and restriction <br />of this and any a the at, ' d as general or special III provisions. <br />Z <br />cnalure licant TitleI Uate <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 ❑ Existing — Type 10 inch corrugated pipe <br />Other pipes in neighborhood: Yes No Approaches U Cross Drain LJ Size 10 inch <br />4. HEADWALL: Yes ❑ No EZ <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way No <br />7, DITCH: Yes ® No ❑ If Yes: V Style ❑ 2 Point ® Other ❑ Width 2 foot Depth 2 feet <br />»»»»»>»»»»»»»»»»»»»»»>»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR X Commercial ❑ Agriculture ❑ Industrial 17`1 <br />Paved with ti% Z "Min Depth A.C. over 7 "Min Depth'/<" A. B, over <br />Notes: <br />2. PIPES: Length of Pipe Required 20 feet R. and Diameter of Pipe 12 inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No EZ <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No EZ <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 />Driveway Encroachment Permit base fee $135.00 0 <br />2� 54 <br />Field In ection <br />DEawayw/or w/o pipe $140.00 BPavedFrontage $116.00+0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />P!fNCROACHAIENI ft Fw sTe"W ENCROACHWWPERW OHNEWAy. o OM <br />