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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 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 orany 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 permissi/tta <br />ited e este , he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any h i ude as general or special III provisions. <br />Si na re of Applicant Title D to <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Difto Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None ❑ Existing—Type bZ" Co E <br />Other pipes in neighborhood: Yes No LJ ApproachesqA Cross Drain Size <br />4. HEADWALL: Yes ❑ No 11 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes A No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR [6� Commercial ❑ Agriculture ❑ Industrial ❑ <br />Notes: <br />2. PIPES: <br />Notes: <br />Paved with L <br />Length of Pipe Required <br />"Min Depth A.C. over <br />� "Min Depth'/<" A.B. over <br />Ft. and Diameter of Pipe �Z � <br />To be connected to any adjacent driveway pipe Yes ❑ No W1Drainage Inlet Required Yes ❑ No ,� <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No ❑ <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 $135.0() <br />Field Inspection <br />Driveway wl or w/o <br />pipe $140.00 <br />Drivewaywlbox Culvert_ _$1131.00 <br />P:{ENCR0.4CHFAENTS1Mesler Farms-TemplateslENCROACHM1IENT PERMIT DRNENIAY.doc (08103) <br />❑Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1,161ft. <br />