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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, indemnity 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 permissio granted as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and a ached sheet, included a general or s ecial III provisions. !7, Z /// <br />Signature of App icanl Title bate <br />»»»>>>>»»»»»»»»>»»»>»»>>>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ Did ❑ _Grravel 0 Aggregate Base El Paved (poor) El Paved (good) ❑ <br />2. SLOPING: Away from Pavement,�l Towards Pavement ❑ Flat ❑ <br />3. PIPES: None K Existing—Type <br />Other pipes in neighhborhood: Yes No Approaches LJ Cross Drain LJ Size <br />4, HEADWALL: Yes EINo P <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No yJ <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ElNoEfdIf Yes: VStyle ❑ 2Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»>»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth 3/4" A.B. over <br />Notes: e <br />2. PIPES; Length of Pipe Required Ft. aVurnberof <br />meter of Pipe /� inch(es) <br />To be connected to any adjacent driveway pipe Yes El No <br />Drainage Inlet Required Yes <br />El <br />Total Length: (with proposed) Total Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />4, <br />PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth %d' 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 ection <br />Driveway w/ or w/o pipe $140.00 a Paved Frontage $116.00 + 0.53/ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />P.IENCROACHMF T& 31x FWWJ"ft aUCROAGHM W PERMIT ORNEWAYtl (=R) <br />