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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 and any att c d sheet, in ed as general or special III provisions. <br />04/15/2020 <br />Signat of Applicant Title C ate <br />»»»»>»»»»»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ Dirt Rr Gravel ❑ Aggregate Base ❑ Paved(poor) El Paved(good) ❑ <br />2. SLOPING: Away from Pavement EJ TowardsPavement E]Flat tove <br />3. PIPES: None R Existing — Type <br />Other pipes in neighborhood: Yes No Z Approaches L.J Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes "I <br />No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No Mr If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»>»»»»»»>»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ❑ Commercial (Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over f!D "Min Depth %` A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe _� <br />I <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No L►4 <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No <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 width <br />»»»»»»»»»»»»»»»»>»»»»»»»»>»»FEES ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 ) \ 121 s,D�R <br />/ <br />Field Ins ection <br />Driveway w/ or w/o pipe $140.00e Paved Frontage $116.00 + 0.53/ft. <br />Drivewayw/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00+1.16/ft. <br />0.1ENL0.0ACHMEMSVksla FamsTanplaleslENCRCACHAENFPERMRCRNEWAYma( <br />