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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 reque�ed, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this�ny attached sheet, inclu d as general or special III provisions. <br />Signa u of Applican TW Date <br />»»»»»>»»»>»»»»»»»>»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />,by EXISTING CONDITIONS <br />1. DRIVEWAY: None 05J 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 neighborhood: Yes KJ. No Approaches Cross Drain LJ Sizeyort <br />4. HEADWALL: Yes ❑ No <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes 9 No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»>>>>»»»»»»>»»»»»»»>»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth Y4" A.B. over <br />Notes: <br />2. PIPES: 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 />Notes: <br />3. HEADWALL: Yes ❑ No <br />Ft. and Diameter of Pipe � inch(es) <br />No <br />No <br />gNumuber of Storm Drain Inlets: <br />4. PAVED FRONTAGE: Paved with <br />P IENCROACNM E MSIAazIer Fmmc-Te,gaks�NGROACHMEM PERMIT ORNEWAY 6x ( <br />"Min Depth A.C. over <br />"Min Depth'/:' A.B. <br />Measuring <br />Feet in length and <br />Feet in width <br />»»>»»>>>>»»>»»>»»»»»»»»»»»»>»»>> F E E S ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee <br />$135.00 <br />Z <br />Field Ins ection <br />Driveway w/ or w/o pipe <br />$140.00 <br />8Paved <br />Frontage $116.00 + 0.53/ft. <br />Driveway w/box Culvert <br />$181.00 <br />Curb, Gutter, Sidewalk $140.00+ 1.16/ft. <br />