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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 performey the ap licant and/or any representative of the application in the County Right -of -Way at the above <br />indicated site with a valid Sannoaquin county Encroachment Permit; and <br />6, a if perm sion is granted a� reque't s g e razc o th work described in accordance with all terms, condition and restriction <br />'of this and a attached sheet inclu d as general or special III provisions. <br />v✓L � �2 2l Z <br />Sig aatu of Applicant life Date <br />»»>»»»»»»»»»»»>»»»»»»>FI LD 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 ❑ FlatA <br />3, PIPES: None Existing—Type <br />Other pi sin neighborhood: Yes No Approaches Cross Drain Size <br />4, HEADWALL: Yes ❑ No 4 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No)( <br />6. BARRIERS: along Right -of -Way <br />7, DITCH: Yes ❑ No it If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»>»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFRX Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over 4 "Min Depth W A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameterof Pipe ft inches) <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total 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 %;' A.B. <br />Measuring Feel in length and Feet in width <br />>>>»»»»»»»»»>>>>>>>»»>>»»»»»>»»»>FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Fie Ins ection � <br />riveway w/ or w/o pipe $140.0 Paved Frontage $116.00 + 0.53/ft. <br />Driveway w/box Culvert $181.00 a Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />%1ENCHOALHMENfSWasle,Forms-TarolelenlENLROALHAENt PFAFYI DPNEVIAY Eao(Ofl98) <br />