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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 a nyattached sheet, included as general or special III provisions. <br />Signature of Applicant Title Date <br />»»»»»»>»»»»»»»>»»»»»>»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. <br />3. PIPES: None ❑ xisting Type mt� C.3-<'CiU fo AIX)) <br />DRIVEWAY: <br />None <br />❑ <br />Dirt ❑ <br />Gravel ❑ <br />Aggregate <br />Base <br />® <br />Paved (poor) ❑ Paved (goad) ❑ <br />2. <br />SLOPING: <br />Away <br />from <br />Pavement <br />❑ Towards <br />Pavement <br />❑ <br />Flat <br />»>»»»»»>»>»»>»>»»»»»>»»»>»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture [Z <br />Notes: <br />2. PIPES: <br />Notes: <br />Industrial ❑ <br />Paved with 7i "Min Depth A.C. over �� "Min Depth W" A.B. over <br />Length of Pipe Required <br />Ft. and Diameter of Pipe 17 � inches) <br />To be connected to any adjacent <br />driveway pipe Yes ❑ <br />Nc <br />Drainage Inlet Required <br />Yes ❑ <br />Other pipes i orhood: <br />Yes M No L Approaches L Cross Drain L Size_J� <br />4. <br />HEADWALL: <br />Yes DEr No ❑ <br />Number of Storm Drain Inlets: <br />5. <br />/ <br />ASPHALT CONCRETE DIKE: Yes No <br />❑ <br />6. <br />BARRIERS: <br />along Rig t -of -Way <br />7. <br />DITCH: <br />Yes No ❑ If Yes: V <br />Style V2Point ❑ Other ❑ Width Depth '�I,_ <br />»>»»»»»>»>»»>»>»»»»»>»»»>»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture [Z <br />Notes: <br />2. PIPES: <br />Notes: <br />Industrial ❑ <br />Paved with 7i "Min Depth A.C. over �� "Min Depth W" A.B. over <br />Length of Pipe Required <br />Ft. and Diameter of Pipe 17 � inches) <br />To be connected to any adjacent <br />driveway pipe Yes ❑ <br />Nc <br />a <br />Drainage Inlet Required <br />Yes ❑ <br />No <br />[� <br />Total Length: <br />(with proposed) <br />Total <br />Number of Storm Drain Inlets: <br />3. HEADWALL: Yes � No ❑ <br />4. PAVED FRONTAGE: Paved with Q l � "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 <br />Field Ins edion <br />Driveway w/ or w/o pipe $140.00 <br />Driveway w/box Culvert $181.00 <br />Ly" Paved Frontage $116.00+0.53/ft. <br />U Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />MNCAOACHMEMSMeslr Fams-Templaln'ENLROACHAFMPEHMIt OPNEWAYtlw( <br />