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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 equested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any attached sh I cluded as general or special III provisions. <br />S4&itdre of Applicant Title ! D to e <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 to <br />3. PIPES: None i[ Existing—Type <br />Other pipes in neighborhood: Y -e T 0 No tk Approaches LJ Cross Drain Size <br />4, HEADWALL: Yes ❑ No Rf <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />7. DITCH <br />along Right -of -Way <br />Yes Er No X If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»»»»»»»>»»»»>>>>»»»»»»»»»>>>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR O Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over "Min Depth %" 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 It <br />Ft. and Diameter of Pipe <br />No <br />No <br />Total Number of Storm Drain Inlets: <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 />»»»»»»>»»»»»»»»»=$135,00 <br />»»»>FEES««««««««««««««««««««««< <br />Driveway Encroachment Permit base fee <br />Field Ins ec6on <br />Driveway w/ or w/o pipe $140.00 8 Paved Frontage $116.00 + 0.53/ft. <br />DrivewaywlboxCulvert 'Ib'I-.0 Curb, Gutter, Sidewalk $140.00+1.16/ft. <br />PIEIDCPOACHMEMS1Matlx FOm TfflT IaRsTNCROACNMENT PEVIT GRIM AYtl (" ) <br />inch(es) <br />