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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 permissi n is granted asrequested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and an' ttagha /q h�e Included as general or special III provisions. <br />�fnd 6 <br />Signature of Applicant Title Vate <br />»»»»»»»»»»»>»»>»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ,j�j Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3, PIPES: None 9 Existing—Type <br />Other pipes in neighborhood: Yes No PC Approaches LJ Cross Drain Lj Size <br />4. HEADWALL: Yes ❑ No A 19 <br />5, <br />ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ Noiz If Yes: VStyle ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»>»»»>»»>»»»»»»»»»>»>»>»>»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFRA Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over *4 "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) TotaNumber of Storm Drain Inlets: <br />Notes: <br />inches) <br />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over. " Min Depth %P A.B. <br />Measuring Feet in length and Feet in width <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> >>>>>>FEES<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />Driveway Encroachment Permit base fee $140.00 <br />Field Ins ectian <br />Driveway wl or w/o <br />pipe $140.00 <br />Driveway w/box Culvert $181.00 <br />XIENCAWgIMFMSUIeebr Fame-TuryYlas"CRWCNAEMPEflN1IgWEWAY.tlao(Afl9B) <br />ePaved Frontage $116.00+0.53/tt. <br />Curb, Gutter, Sidewalk $140.00+1.16/tt. <br />