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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. 1 hat 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 as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />t, included as general or special III provisions. <br />— <br />qnzm Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONL'►')««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt 'Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br />3. PIPES: None JV Existing–Type <br />Other pipes in neighborhood: Yes Lj No Approaches 4K Cross Drain H Size <br />4. HEADWALL: Yes ❑ No 4K <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />7. DITCH <br />along Right -of -Way <br />Yes El No W <br />If Yes: V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />�f rta.et �a <br />�t/os�l a <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR n Commercial E] Agriculture ❑ Industrial ❑ <br />Notes: <br />2. PIPES: <br />Notes: <br />Paved with Z <br />Length of Pipe Required <br />"Min Depth A.G. over <br />"Min Depth'/" A.B. over <br />Ft. and Diameter of Pipe �/ inch(es) <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. I�EADWALL: Yes ❑ <br />4. PAVED FRONTAGE: Paved with "Min Depth R.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 pipe $140.00 <br />_ Drivewayw/box Culvert_ _$181.00 <br />P:IENCRCACHM1IENTSIM1Iastar 17crms-TemplateslENCRCACHIv1ENi PERMIT ORIVEWA}'.dw (08148) <br />APaved Frontage X11 G.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />