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THE APPLICANT HEREBY CERTIFIES: <br />1. That helshe 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 ansa 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 Rightof-Way at the above <br />Indicated site with a valid San Joaquin County Encroachment Permit; and <br />V. That if permission is granted as requested, he agrees to do the work described in accordance wish all terms, condition and restriction <br />of this and an eche sheet, included as general or special III provisions. , // <br />Signatur6 of Applip7dibit Title uate <br />>»»»»»»»»»»»»»»>»>»»»»FIELD 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 ❑ Flat( <br />3, PIPES: None Existing -,Type <br />Other pipes in nepigghborhood: es No Approaches Cross Drain Size <br />4. HEADWALL: Yes ❑ No k <br />5. ASPHALT CONCRETE DIKE: Yes ❑ NoO <br />6. BARRIERS: along Rightof-Way <br />7. DITCH: Yes ❑ No Q� If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>»»»»»»»»»»»»»»»»»»»»»»»>PERMITS REQUIREMENTS«««««««««««<c««««««««« <br />4. DRIVEWAY: SFR 0� Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over "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) Tota Number 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 3/4" A.B. <br />Measuring Feet In length and Feet in width <br />»>»»»»»»>»>»»»»»>»»»>»»»»>»»>»>FEES«««««««««««««««««««««««««<<<< <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins 'on <br />Dnvewayw/or w/o pipe $140.00 <br />Driveway w/box Culvertbbbb$181.00 <br />ePaved Frontage $116.00 + 0.53Ift <br />Curb, Gutter, Sidewalk $140.00+ 1.t61tt. <br />