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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 andror 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 and any attached sheet, included as general or special III provisions. <br />6-1-20 <br />Signature of Applicant Title Uale <br />>»»»»»>»>»»>»»>»»»»»>»»>FIELD INSPECTION OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CO DITIONS <br />1. DRIVEWAY: None ❑ DirIX Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flatek <br />3. PIPES: None Existing—Type <br />Other pipes in neighborhood: Yes N Approaches Cross Drain Size Or <br />4. HEADWALL: Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes ❑ NoO <br />6. BARRIERS: along Right•of•Way <br />7. DITCH: Yes ❑ No JIf Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture ❑ Industri <br />Noies: <br />2. PIPES: <br />Notes: <br />al ❑ <br />Paved with "Min Depth A.G. over. "Min Depth �/l A.B. over <br />Length of Pipe Required <br />Ft. and Diameter of Pipe <br />To be connected to any <br />adjacent driveway pipe Yes ❑ <br />No <br />❑ <br />Drainage Inlet Required <br />Yes ❑ <br />No <br />❑ <br />Total Length: <br />(with proposed) <br />Total <br />Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No ❑ <br />inches) <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 $135.00 <br />Field Ins ection <br />Driveway wl or w/o pipe $140.00 <br />Driveway w/box Culvert $151.00 <br />P-FNCIgACNAWSMuhfFams-TmpbxiFNGgRtM4EM PERMRORNEWAYEx I%%1 <br />Paved Frontage $116.00+ 0.53/ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16lft. <br />