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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.helshe will assume full responsibility for ail liability for persona; injury or damage to property which may arise out or 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 andlor 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 requeste I, he agrees to do the work described in accordance with all terms, condition and restriction <br />of thi �d jany attached sheet, i clude s general or special III provisions. <br />—� ignature of ApplicaN Titl Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD Ild SPECTION (OFFICE USE ONLY)««««««««««««« <«««««< <br />EXISTING CONDITIONS <br />1. DRIVEWAY <br />2. SLOPING: <br />3. PIPES: <br />4. HEADWALL <br />None ❑ Dirt AGravel ❑ <br />Away from Pavement ❑ <br />Towards <br />None Existing - Type <br />Other414.s in neighborhood <br />Yes ❑ No <br />Aggregate Base ❑ Paved (poor) ❑ <br />Pavement ❑ <br />Flat L <br />I <br />Paved (good) ❑ <br />Yes <br />No <br />Approaches <br />Cross Drain <br />Size <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No , <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No If Yes: V Style El Point ❑ Other ❑ Width _ Depth <br />»»»»»»>->»»»»»>»»»»»»»»»»>>>PERMITS REQU[RE tNENTS««««««««««««««««««««« <br />E] <br />1. DRIVEWAY: SFR' Commercial ❑ <br />Paved with <br />Notes: <br />2. PIFES: <br />Notes: <br />Length of Pipe Required <br />Agriculture F-1Industrial <br />in Depth A.C. over 9 <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required 1'es ❑ <br />Total Length: (with proposed) <br />"Min Depth 3/" A.B. over <br />. Ft. and Diameter of Pipe � <br />No d <br />No <br />Total !\1umber of Stone Drain Inlets: <br />inches) <br />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over. " Min Depth '14" A.B. <br />Measuring _ Feet in length and Feet in width <br />>>»»»»>>>>>»»;P>>5>»»»»>>>;>>>>>»» »»»>>>> FEF <br />Driveway Encroachment Permit base fea$` 35.00 <br />Field Inspection <br />� <br />Driveway w/ or w/o$140,00 ❑ Paved Frontage6.0 <br />$110 f, <br />0.53/ft. <br />[ Drivevvayv!dbox Culvert._ _._ ❑$181.00 Curb, Gutter, Sidewalk _$140.00 )1.1G/fi, <br />F1ENCROACHMENTAiWasler Forms-TemplalesTNCROACHMENT PERMIT ORIVEWAY.do. (08108) <br />