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THE APPLICANT HEREBY CERTIFIES: <br />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 attached sh at, included as general or special III provisions, <br />vl i �G - 2.� r 1 c <br />Vn ture of Applicant Title Date <br />»»>»»»»>»»»>»»> >»»»»>»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base Paved (poor) Rr Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />r <br />3. PIPES: None ❑ Existing—Type Z L'orJGekATC <br />Other pipes in neighborhood: Yes Jt No Approaches Cross Drain Size 14 FM <br />4. HEADWALL: Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No 2 <br />6. BARRIERS: along Right -of -Way <br />7, DITCH: Yes 0 No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»>»»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR kl Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth'/," A.B. over <br />Notes: <br />2, PIPES: Length of Pipe Required Ft. and Diameter of Pipe % inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No K <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 Feet in length and Feet in width <br />>»»»»»»»»»»»»»»»»»»»»»»»»»>>>FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway wlorw/opipe <br />$121.00 ❑Paved Frontage $116.00+0.53/ft. <br />Driveway w/box Culvert $181.00 �] Curb, Gutter, Sidewalk $121.00+ 1.16/ft. <br />K1 NGi0ACHMENTN&sler Fons TUr0t11ENM0ACNAIENT PFAAIN MNWAY.tl 1M ) <br />