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THE APPLICANT HEREBY CERTIFIES: <br />1$ That he/she has read all the provisions of this application, and that [lie 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 />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 gran ads, equested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any attached ee , included ageneral or special III provisions. <br />y / 3 f <br />ignature of Applicant Title Dat <br />»»»»»»»»»»»»»»»»»»»»>FIELQ INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY <br />2. SLOPING; <br />3. PIPES <br />4. HEADWALL: <br />None ❑ Dirt �] Gravel ❑ <br />Away from Pavement ❑ <br />None k. Existing — Type <br />Other pipes in neighborhood <br />Yes ❑ No,� <br />Aggregate Base ❑ Paved (poor) ❑ <br />Towards <br />Pavement ❑ <br />Flat T <br />Paved (good) ❑ <br />Yes <br />No <br />Approaches <br />Cross Drain <br />Size <br />5. ASPHALT CONCRETE DIKE: Yes 1`71 No <br />6, <br />BARRIERS <br />7. <br />along Right -of -Way <br />DITCH <br />_ <br />Yes El& No If Yes <br />V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REO,IJ I RE MENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR,�Commercial ❑ <br />Notes: <br />2. PIPES <br />Notes: <br />3. HEADWALL <br />Length of Pipe Required <br />`/ <br />Agriculture F1Industrial�❑ <br />Paved with 2-' <br />"Min Depth A.C. over 7 "Min Depth'/" A.B. over <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 "Min Depth A,C. over "Min Depth 3/" 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 wl or w/o pipe $1 <br />40.00 <br />Driveway wlbox Culvert _$181.00 <br />P:IENCROACNMENTS1Masler Fanns-TemplalesTINCROACEMBF PERMIT DRIVEWAY.dec (08,08) <br />❑ Paved Frontage $116.00 + 0.53lft. <br />[] Curb, Gutter, Sidewalk $140.00 -� 1.161ft. <br />