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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 />b. That if permission Is granted as r Iu ted, he agrees to tlo the work described in accordance with all terms, condition and restriction <br />of <br />Is and an attached see e ed as general or special III provisions. <br />(XA °r 7� / /� 2 - <br />Signature <br />Signature of Applicant Title ate <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 r42 <br />3. PIPES: None Existing — Type <br />Other pipes in neighborhood: Yes Lj No Approaches L Cross Drain Lj Size <br />4. HEADWALL: Yes r-1NoQ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No� <br />b. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No te <br />If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />DRIVEWAY: SFR X Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved withy "Min Depth A.C. over "Min Depth 3/4" A.B. over <br />Notes: <br />2. PIPES: 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 />Notes: <br />Ft. and Diameter of Pipe <br />Na <br />No <br />Tota Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth 3/4" A.B. <br />Measuring Feet in length and Feet in width <br />inches) <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee1�$135.00 <br />Field Ins ection <br />Driveway vi/ orw/o pipe <br />$140.00 <br />e wlbC$181Paved Frontage $116.00+0.531ft. <br />Driveway ox ulvert .00 <br />PYNCROACHMENiSWaMx Pmm-iemgaleS£NCROACHMENEPERMRRRNEWAY.tloc@&W <br />Curb, Gutter, Sidewalk <br />$140.00+ <br />1.161ft. <br />