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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 as requested, he agrees to do the work described in accordance with all terns, condition and restriction <br />of this and any attached eet, included era/ or special III provisions. <br />SCJ ginnatil P of Annlirnnt Title (v Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel Q]� Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None ❑ Existing —Type <br />Other pipes in neighborhood <br />4. HEADWALL: Yes ❑ No It <br />A <br />Yes No Approaches Cross Drain Size <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No. <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes 10 No ❑ If Yes: V Style ❑ 2 Point F] Other El Width Depth <br />»»»»»»»»»»»»>»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY <br />Notes: <br />2. PIPES: <br />Notes: <br />SFR ❑ Commercial 05 Agriculture ❑ Industrial ❑ if <br />Paved with <br />Length of Pipe Required <br />"Min Depth A.C. over �% "Min Depth'/" A.B. over <br />Ft. and Diameter of Pipe I <br />To be connected to any adjacent driveway pipe Yes ❑ No cmc <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 />inches) <br />"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 eciion <br />Driveway wl or w/o <br />pipe $140.00 <br />Dr(veway w/box Culvert $181.00 <br />P:IENGROACHMENTS1Masler Forms-TemplaleslENCROACHMENT PERMIT ORIVEWdI'.doc (08108) <br />❑Paved Frontage $116,00 + 0.531ft, <br />Curb, Gutter, Sidewalk _$140.00 + 1.161ft. <br />