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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 permissio 's granted as requested, he a tees to do the work described in accordance with all terms, condition and restriction <br />of this and ached t, included a g ral or special III provisions. <br />2� <br />Signa ure o plicant T(e Dale <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY; None ❑ Dirt ❑ Gravel ❑ Aggregate Base � Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement K Towards Pavement ❑ Flat ❑ <br />3. PIPES: None a <br />Existing —Type <br />Other pipes in neighborhood: <br />4. HEADWALL: Yes ElNo <br />Yes <br />No <br />Approaches <br />Cross <br />Drain <br />Size__IL <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No� <br />6. BARRIERS <br />7. <br />along Right -of -Way <br />DITCH <br />Yes ElNo k If Yes: V Style <br />❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR A Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with � "Min Depth A.C. over _ "Min Depth '14" A.B. over <br />Notes: <br />2. PIPES <br />Notes: <br />Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />3. HEADWALL: Yes ❑ <br />4. PAVED FRONTAGE; <br />No� <br />Paved with <br />Measuring <br />Ft. and Diameter of Pipe <br />No 1 <br />Nok <br />Total Number of Storm Drain Inlets: <br />"Min Depth A.C. over <br />Feet in length and _ <br />"Min Depth'/4' A.B. <br />=eet in width <br />inches) <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 ,�. a6 <br />' Id Ins ection ��� � <br />Driveway w/ or w/o pipe $140.00 <br />LII�Driveway w/box Culvert $181.00 <br />P:IENCROACHMENTSIMaslar Forms-TemplaleslENCRDACHMENT PERMIT DRIVEWAY,doo (08I08) <br />❑Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />