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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 d sheet, included as general or special III provisions, <br />re of Applicant ate <br />>»»»»»»»»»»»>»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt4 Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 9 <br />3. PIPES: None, Existing—Type L <br />Other pipes in neighborhood: Yes LJ No Approaches LJ Cross Drain LJ Size <br />4, HEADWALL: Yes ❑ No It qq,�� <br />5. ASPHALT CONCRETE DIKE: Yes El No CSI <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No " i If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»>»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR 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 Ft. and Diameter of Pipe �//i inches) <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: T�'*/ 14 y -W Topd05AeAle4L io;� 4!yw jr)ez) <br />3. HEADWALL: Yes ❑ No�J <br />4, PAVED FRONTAGE: Pavedwith"Min Depth A.C. over " Min Depth 3/4" A.B. <br />Measuring Feet in length and Feet in width <br />»»»>»»»»»»»»»»»»»»»»»»»»»»» > F E E S ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee ' $135.00 <br />Field Ins ection <br />Driveway w/ or w/o <br />pipe $140.00 <br />DrivewaywlboxCulvert $181.00 <br />P!ENCPOACNFIFMStNesler FamsiemMakAENCFOACHMENI PEflMNOflIVEWAY.Ea(OBtlB) <br />®Paved <br />Frontage <br />$116.00+0.53/ft. <br />Curb, Gutter, Sidewalk <br />$140.00 <br />+ 1.16/ft. <br />