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THE APPLICANT HEREBY CERTIFIES: <br />1, <br />2. <br />3. <br />4. <br />5, <br />6, <br />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 />That he/she is the owner of the respective property, or is qualified to represent the owner; and <br />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 />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 />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 />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 a ieneral or special III provisions, ' <br />t�fis Z/ 7 <br />Signature o Applicant Title Dat <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 ❑ Towards Pavement ❑ Flat (�- <br />3. PIPES: None INA <br />_ Existing —Type <br />Other pipes in neighborhood <br />4, HEADWALL: Yes ❑ No M <br />Yes <br />No <br />Approaches <br />Cross <br />Drain <br />Size <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7, DITCH: Yes ❑ No dX If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY; SFR FK <br />Notes: <br />2, PIPES: <br />Notes: <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2i "Min Depth A.C. over "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 t�i <br />- <br />Drainage Inlet Required Yes ❑ No ��_ <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No�j� <br />4. PAVED FRONTAGE: Paved with <br />Measuring <br />"Min Depth A,C, over <br />Feet in length and _ <br />"Min Depth'/4' A.B. <br />=eet in width <br />inches) <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135,00 <br />Field Ins ection <br />Driveway wl or w/o <br />pipe $140.00 <br />Dr)veway wlbox Culvert $181,00 <br />P:IENCP.DACHIdENiblMarder Forms-TemplateslEIJCROACHIAENT PERMIT DRIVEWAY.doc (08/08) <br />❑Paved Frontage $116.00 + 0,531ft. <br />Curb, Gutter, Sidewalk $140,00 + 1,161ft, <br />