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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 a dd aaItac�h d sheet included as general or special III provisions. <br />ti Signature of Applicant Title Dale <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 (J Towards Pavement ❑ Flat ❑ <br />3. PIPES: None Existing—Type <br />Other pipes in neighborhood—Yes-g No LJ Approachesj6 Cross Drain LJ Size <br />4, HEADWALL: Yes ElNob <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7, DITCH: Yes k No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»» /»»»»»»» »»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR/,IiJ Commercial E] Agriculture ❑ Industrial <br />—❑ <br />Paved with "Min Depth A.C. over 1 "Min Depth M" A.B. over <br />Notes: <br />` 11 <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe I Z inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ N <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total umber of Storm Drain Inlets: <br />Notes: qqq,,, <br />3. HEADWALL: Yes ElNod <br />4. PAVED FRONTAGE: Paved (with "Min Depth A.C. over. "Min Depth''/," A.B. <br />Measuring Feet in length and T Feet in width <br />»»»»»»»»»»»»»»>»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Inspection <br />Driveway w/or w/o pipe $140.00 Paved Frontage $116.00+0.53/ft. <br />Drivewayw/box Culvert $181.00 H Curb, Gutter, Sdewalk $140.00+1.16Kt. <br />P.%ENW0ACNEMSMasW Fmms T moateslENCROACNMENT PERMIT ORWMAY.dx(MO) <br />