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THE APPLICANT HEREBY CERTIFIES: <br />1. That helshe 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 nted s requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any alt ed sh , incl U as general or sp tial III provisions. <br />Sign r df App icant Title <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 <br />3. PIPES: None k Existing—Type <br />Other pipes in neighborhood: Yes No Approaches Cross Drain LJ Size <br />4, HEADWALL: Yes ❑ NoIX <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No K <br />6. BARRIERS: <br />along Right -of -Way <br />7. DITCH: <br />Yes ❑ NoXlf Yes: V Style ❑ <br />2 Paint ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»a»»»»»,»r>»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commorrcial aA Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over (10, "Min Depth %" 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 />No <br />No <br />Total Number of Storm Drain Inlets: <br />inches) <br />3. HEADWALL: Yes ❑ Na� <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth %" A.B. <br />Measuring Feet in length and Feet in width <br />»»>»»»»»»» >»»>»»»»» » >»»»»»»»»FEES««««««««««««««««««««««««««« Cd <br />Driveway Encroachment Permit base fee $140.00\ <br />Field Ins ection /) <br />Driveway w/ or w/o pipe $140.00 B Paved Frontage $116.00 + 0.531ft, <br />iveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.16/fl. <br />KiENtAOACHAIEMSWasler FamrTemdakslX:tR0.4CXMENi PERAIIi ORNEWAY.doc(06tlB) <br />