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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 properly, 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 pe sion is granted ase ested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this a d a attached sheet incl ded as general or special III provisions. / <br />Siqnature of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (GFFICE 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 [I Towards Pavement ❑ <br />Nonet Existing — Type <br />Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes El No f If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ,�] Commercial ❑ Agriculture E] Industrial ❑ <br />Paved with Z" "Min Depth A.C. over � "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 ❑ <br />Total Length: (with proposed) <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />Ft. antl Diameter of Pipe <br />No <br />No <br />Total umber of Storm Drain Inlets: <br />inches) <br />4, PAVED FRONTAGE: Paved with "Min 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 wl or w/o <br />pipe $140.00 <br />Driveway wlbox Culvert $181.00 <br />P:IENCRCACHIAENTS1Masfer FoimsdemplaleslENCRCACHM1IENT PERMITDRNEWAY.doc (08108) <br />[] Paved Frontage _$'I 16.00 + 0.531ft. <br />[] Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />