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tc <br />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 assurne 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 attach s t included as general or special III provisions. r <br />Signature of Ap licant Title Date <br />»»»»»»»»»»»»»»»»»»»»> F I ELD 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 Pavernent ❑ Flat <br />3. PIPES: None f k " Existing — Type <br />Other pipes to neighborhood: Yes No Approaches H Cross Drain Ll Size <br />4. HEADWALL: Yes ❑ No KN <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No OKI <br />G. BARRIERS: <br />7. <br />along Right -of -/Nay <br />DITCH <br />Yes El No If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR M Commercial <br />❑ Agriculture ❑ Industrial ❑ <br />Paved with • "Min Depth A.C. over �(' <br />i"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 E]Total Length: _ (with proposed) <br />Notes: <br />Ft. and Diameter of Pipe !V <br />No <br />No <br />Total umber of Storm Drain Inlets: <br />inches) <br />3, HEADWALL: Yes ❑ No,� <br />4. PAVED FRONTAGE: Paved with _ "Min Depth A.C. over " Min Depth "74 A, be <br />Measuring Feet in length and , Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base <br />pipe <br />Driveway w/box Culvert. <br />fee $135.00 <br />Field Ins ection <br />Driveway wl or w/o <br />$140.00 <br />$181.00 <br />P.IEI•:CROACHMEIITSLMasler Eorms-TemplaleelEMCkOAGHMENT PERAdIi �PoVEWAY,doc (OB/OBr <br />Paved Frontage $11 G.00 + 0.53/ft. <br />Curb, Gutter, Sidewalk_ $140.00 + 1,16/ft. <br />I1 <br />