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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 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 s requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this a9A alta ed e , included as general or special III provisions. <br />- 2U <br />ignature of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt �] Gravel ❑ Aggregate Base ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None 17V <br />Existing —Type <br />Other pipes in neighborhood: Yes <br />4. HEADWALL: Yes ❑ No 1 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No Ad <br />6. BARRIERS: <br />7. <br />along Right -of -Way <br />DITCH <br />Yes ❑ No x If Yes: <br />Paved (poor) ❑ <br />toss <br />V Style ❑ 2 Point ❑ Other ❑ Width <br />Paved (good) ❑ <br />Depth <br />»»»>»»»»»»»»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over. "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />Ft, and Diameter of PipeZriVT <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 />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with <br />Measuring <br />"Min Depth A.C. over "Min Depth 3/" A.B. <br />Feet in length and Feet in width <br />>>>>>>>>>>>>>$>>>>>>>>>>>>>>>>>>>> <br />>>>>>>FEES <br />inches) <br />««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $ i 35.00 <br />Field Ins ep ction <br />Driveway w/ or w/o pipe $140.00 <br />Driveway w/box Culvert_ $181.00 <br />P:IENCRUACHIdENTSIMasler Forms-TemplatesfENCRUACHMENT PERMIT URIVEWAY,doc (08108) <br />ePaved Frontage $116.00 + 0.53/ft. <br />Curb, Gutter, Sidewalk _$140.00 + 1.161ft. <br />