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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 granted as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this an/y attached sheet, included as general or special III provisions. <br />`-'l Signature of Applicant Title I teate I <br />»»»»»»»»»»>»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ADirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flatdh <br />3. PIPES: None Existing - Type <br />Other 'pies in neighborhood: Yes LJ No& Approaches Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ Noit <br />5, ASPHALT CONCRETE DIKE: Yes ❑ Nok <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No/C If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»»»»»>»»»»»»»>»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR)( Commercial [-]Agriculture ❑ Industrial [IPaveed with if "Min Depth A.C. over V "Min Depth '14" A.B. over <br />Notes: Aanle&-Vt! AOA<a4cX AOO ar[ C'�eiM 57P ae 6Co <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 />3. HEADWALL: Yes ❑ No/ <br />Ft. and Diameter of Pipe <br />No <br />No <br />Total Number of Storm Drain Inlets: <br />inch(es) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth '/4" A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»>»»»»»»»»»»»»»»>»»»»»»FEES ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Field Insinection <br />Driveway wl or w/o pipe $140.00 <br />Driveway wlboxCulvert $181.00 <br />Xi NMR CHYENT=a5W Fwm-Templ,la NCR0CHJKEW KW WIVMAY.k �") <br />Paved Frontage $116.00 +0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />