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I HE 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 attached sheet, included as general or special III provisions, <br />L Sinnatl Ira of Annlirant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFf=ICE 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 ❑ Flatjg <br />3. PIPES: None FA -7 <br />Existing—Type <br />Other pipes in neighborhood,' Yes Li <br />4. HEADWALL: Yes ❑ No 4 — <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No [bf <br />No Approaches Cross Drain Size <br />G, BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No eg If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»P ERM ITS REQUI REM ENTS««««««««««««««««««««« <br />1. DRIVEWAY <br />Notes: <br />SFR Pkf Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A,C, over <br />2, PIPES: Length of Pipe Required <br />Notes: <br />"Min Depth 3/" A.B. over <br />Ft, and Diameter of Pipe <br />To be connected to any adjacent driveway pipe Yes ❑ No 4d <br />Drainage Inlet Required Yes ❑ No <br />Total Length: _ (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with <br />inches) <br />"Min Depth A.C, over "Min Depth 3/4' A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»1=EES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Inspection <br />Driveway vvl or wlo pipe $140.00 <br />Driveway wlbox Culvert $181.00 <br />P:IEMGROACRfAEIJTSWasler Forms-Templzle s1ENCR0ACHIvIEIJT PF_RIdR DRIVEWAY.Aor, (OBICB <br />Paved Frontage $11G,00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140,00 + 1.16/ft, <br />