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1'14E APPLICANT HE=REBY CERTIFIES: <br />L 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 helshe 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 Righl-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 and any attached sheet, Included as general or special III provisions. <br />Signature of Applicant Title bate <br />»»>»»»»»»»»»»»»»»»>»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None Z/Dtd ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from P vement E] Towards Pavement E] Flat <br />3. PIPES: None j�xlsting—Type _z <br />Other pipes in neighborhood: Yes U No rj Approaches LJ Cross Drain Size <br />4, HEADWALL: Yes ElNo E //// <br />54 ASPHALT CONCRETE DIKE: Yes ElNo E3 <br />6. BARRIERS: along Rfght-of-Way <br />7. DITCH: Yes ❑ No If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>>>>>>>>>>»>>>>>>>>>»>>>>>>>>>;>>>>>>> <br />� »»»»PERMITS REQUIREMENTS«a«««<a««««««<«««««««« <br />1, DRIVEWAY: SFR El Comm( CommLd Agriculture ❑ Industrial ❑ <br />Paved with L "Min Depth A.C. over vo "Min Depth %" 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 />No �1 <br />No ©` <br />To <br />3. hIEADWALL: Yos ❑ No Lvl <br />Number of Storm Drain Inlets: <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth %" A.B. <br />Measuring �_ Feet in length and —Feet In vridth <br />»»>»>»>»»>»»»»»»»»»»»»»»»»»»»FEES <r, «««««««««««««««««a ««««««<<<< <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Drivekay wl or W/o <br />pipe $140.00 <br />Orlveway w/box Culvert $181.00 <br />niur.�ma�.,:nri.,,.., r„rc. rN„av�ua:mcurs�rxmmonrvnvnv�."cazeai <br />�`� PavedFranlage_ $116.00+0.53/it. <br />❑ burb, Gutter, Sidewalk— $140,00.�.1.16/ff. <br />