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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 gr nted as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any attach sheet, included as general or special III provisions. <br />. 01110122, <br />gn 'Gant Title Date <br />»»»»»»»»>»»>»»»>»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ <br />2. SLOPING: <br />3, PIPES: <br />Away fr���o(((m P <br />NoneOther pi es <br />4. HEADWALL: Yes ❑ <br />Dirt Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />avement ❑ Towards Pavement ❑ Flat& <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />7. <br />along Right -of -Way <br />DITCH: <br />as ElNof Yes: <br />V <br />Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR Commercial ❑ Agriculture ElIndustrial FIPaved with fo� "Min Depth A.C. over 64 "Min Depth Y4" A.B. over <br />Notes: <br />2. PIPES: <br />Notes: <br />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 />Ft. and Diameter of Pipe � <br />Na <br />No <br />Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth Y4" A.B. <br />Measuring Feet in length and Feet in width 00 <br />inches) <br />>»»>»»»»»>»»>»>»»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00��2� <br />F100 DriIns eclion <br />vewa/or w/o pipe $140.00a Paved Frontage $116.00+0.53/ft. <br />Driveway wlbox Culvert$181.00 Curb, Gutter, Sidewalk $140.00+ 1.16/ft. <br />K`ENgVDAG1IAENF51Metlx FamsTe"pWa1ENpIWCNMEMPERMII DRNEWAY tl""(OBR91 <br />