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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 (lability 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 top 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 she with a valid San Joaquin County Encroachment Permit; and <br />6. That it permission is granted as requested, he agrees to do the work described in accordance with all terms, condition and rostriction <br />of this and any attached sheet, included as general or special III provisions. <br />vie ItiemC!`e, Ii-UZ_21 <br />vbignature otApplicantTitle Uale <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None Cf Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />n <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat j <br />3. PIPES: None Existing—Type <br />Other apes in neighborhood: Yes Ll No Approaches Ll Cross Drain Size <br />4. HEADWALL: Yes ❑ No �( <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right-oi-Way <br />7. DITCH: Yes ❑ No r1V <br />Ii Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ;K Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over "Min Depth 3/a" A.B. over <br />Notes: <br />2, PIPES: Length of Pipe Required Ft. and Diameter of Pipe lA inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Tota! Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth 1/411U, <br />Measuring Feet in length and Feet In width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee 8135.00 <br />Field Ins ection <br />Driveway w/or w/o pipe $140.00 Paved Frontage 8116.00+0.53/ft. <br />Drlvewayw/boxCulvept $181.00 a Curb,Gulter,Sldewalk 8140.00+1.16/8. <br />RMJCROADHMEIrt du FamsTOMWOMFNCROACHMENT PERMIT DRNEN'AY.Jw(Alo <br />