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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 responsty 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 attached sheet, included as general or special III provisions. <br />.�.ow©WNL I20t7 <br />Signatu e of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: <br />2. SLOPING: <br />3. PIPES: <br />4. HEADWALL <br />None ❑ Dirt Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ❑ Towards Pavement ❑ Flat j�-- <br />None (id <br />— Existing —Type <br />Other pipes in neighborhood <br />Yes ❑ No k <br />Yes No Approaches Cross Drain Size IZ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No �f <br />6. BARRIERS: <br />7. <br />along Right -of -Way <br />DITCH: <br />as P5No El <br />If Yes: V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR 9 <br />Notes: <br />2. PIPES: <br />Notes: <br />3. HEADWALL <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over 4 "Min Depth'/" A.B. over <br />Length of Pipe Required <br />Ft. and Diameter of Pipe <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 />inches) <br />4. PAVED FRONTAGE: Paved with "Ain Depth A.C. over "Min Depth'/" A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway w/ or w/o <br />pipe <br />Driveway w/box Culvert_ <br />X140.00 <br />� 181.00 <br />P:�ENCROACHMENTSIMuskr Fatma-iempiatas'iEHCRCACHMENT PERMIT �RIVEWAY.dm (08108) <br />❑Paved Frontage X116.00 + 0,531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />