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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 helshe 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 shaji be performed byy the <br />indicated site with a valid San Jeai u <br />6. That if permission is granted as <br />of this and any attached sheet, <br />and/or any representative of the application in the County Right -of -Way at the above <br />Encroachment Permit; and <br />o <br />na:nlc�e wiat.h a�ll te�1rm, s,nc�ondit�ion a <br />nd restiction <br />»»»»»»»»»»»>>»»>»»>»»>>>FIELD INSPECTION(OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt 'w Gravel ❑ Aggregate Base i J Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement V Towards Pavement ❑ net <br />3. PIPES: None jg Existing -Type <br />Other (pipes in neighborhood: Yes LJ No Approaches U Cross Drain U Size <br />4. HEADWALL: Yes ❑ No V J <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No Lr <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No JP0,1f Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»>»»»»»»»»»»»»»>PER�IITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR [:]Commercial ❑ Agriculture Industrial ❑ <br />Notes: <br />2. PIPES: <br />Notes: <br />Paved with Z 'Min Depth A.C. over /0 "Min Depth %* A.B, over <br />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 />Ft. and Diameter of Pipe <br />No <br />No <br />Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No 0 <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth 1/4" A.B. <br />Measuring Feet in length and Feel in width <br />inch(es) <br />»»»»»»»»»»»»»»»»» »»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins lion <br />Dlq-Ddveway w/ or wlo pipe $140.00 8 Paved Frontage $116.00 + 0.5318. <br />rl Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.1618. <br />KMT9Rfh M 1,'fi, <br />