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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 permis jeers granted as requested, he agre d th dork described in accordance with all terms, condition and restriction <br />of this and attached sheet, includ s ge alis aI III provisions. <br />Aoo <br />Sign ure n pl cant Title me <br />>>>> > »»»»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY <br />2. SLOPING <br />3. PIPES <br />4. HEADWALL: <br />None � Diit ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ElTowards Pavement ❑ Flat <br />None �( Existing —Type <br />Other pipes in neighborhood <br />Yes ❑ No J4 <br />Yes <br />No <br />Approaches <br />Cross Drain <br />Size <br />5. ASPHALT CONCRETE DIKE: Yes E] No <br />6, BARRIERS: along Right-of-INay <br />7. DITCH: Yes ❑ No K If Yes: V Style El <br />2 Point ❑ Other ❑ Width <br />Depth <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR k Commercial ❑ Agriculture r]Industrial F1Paved with L^ _ "Min Depth A.C. over _ "Min Depth'/4' A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft, and Diameter of Pipe <br />r <br />To be connected to any adjacent driveway pipe 1'es ❑ No <br />Drainage Wei. Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3, HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with <br />Measuring <br />"Min Depth A.C, ever <br />Feet in length aril __ <br />" IU�ir, Depth 3/4" A.B. <br />=eat In width <br />incti(es) <br />»»»»»»»»»»»»»>»»»»»»»>»»»»»»FEES«««« <br />Driveway Encroachment Permit base fee____ $'Ifl i , <br />1 14 <br />Field Inspection %, <br />Driveway w/ or w/o pipe $1 ) P''' w `' Paved Frontage_ $116.00 + 0.53/ft. <br />Driveway w/box Culvert_ __$181.00 ❑ Curb, Gutter, Sidewalk___$121.00 + 1,16/ft. <br />X.IENGROAGMIENTSIMzsler Fo"ns-1 "mpltleslEIJCROhCHILEItlT PEF.IdIi GRNENkY.uoc ( <br />03/03) <br />