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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 />50 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 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 as general or special III provisions. <br />SioBtuf of plicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: <br />2. SLOPING <br />3. PIPES: <br />4. HEADWALL: <br />None ❑ Dirty]/ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ❑ <br />None 4 Existing—Ty <br />Other pipes in neighborho <br />Yes ❑ No <br />RETE <br />gar <br />F-1 <br />5. ASPHALT On <br />DIKE: Yes <br />No <br />Towards Pavement ❑ Flat <br />es <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes E]No 9 If Yes: V Style El <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»>»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over if. "Min Depth'/" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />Ft. and Diameter of PipepAgn <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 Stone 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 />INeasuring Feet in length and Feet in width <br />»»»»»»»»»»»»»» >»»»»»»»»»»»» > F E E S «««««««««««««««<: «««««««««««< <br />Driveway Encroachment Permit base fee $135.00 <br />1=field Ins ection <br />Driveway wl or w/o <br />pipe_ $140.00 <br />Driveway w/box Culvert $181.00 <br />P:IENCRCACHh1ENTS1Masler Partes-TenplxteslENCRCACHMENT PERMIT ORIVEWAY.doc (08104) <br />❑ Paved Frontage $116.00 + 0.531ft. <br />[] Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />