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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 accordance with all terms, condition and restriction <br />of this and any attached sheet, included as general or special III provisions. / <br />0 0(-)4 0^� � 0-'C:1 � �L®t�/ <br />� <br />v signature�pplicantTitleatm <br />>»>»»»»»»»»»»»»>»»>»»»>FIELD INSPECTION ( OFFICE USE <br />ONLY)««««««««««««««««««« <br />,�/ EXISTING CONDITIONS <br />1, DRIVEWAY: None L9' Dirt ❑ GrayE]el Aggregate Base ❑ Paved (poor) El Paved (good) El2. SLOPING: Away from Pavement VU/ Towards Pavement ElFlat El3. PIPES: None L//Existing-Type <br />Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br />4. HEADWALL: Yes ❑ No <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />along Right -of -Way <br />7. DITCH: <br />as ElNo EKf Yes: V Style F]2 Point ElOther F-1Width <br />Depth <br />»»»>» »»»»»»»»»»»»»>»>»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR golf <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with -v "Min Depth A.C. over "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe n <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 />inches) <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 />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field lns ection Paved Fronta a $116.00+0.531ft. <br />Drivewayw/orw/o pipe <br />$140.00 $181.00 a 9 <br />Driveway wlbox Culvert Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />RUCROACHM Mcsbrt PE WUR Aytl 0'00) <br />