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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 liaty 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 />of this and any attached sheet, included as general or special III provisions. <br />L� x 09/25/2020 <br />Signature of Applicant 1Y <br />Date <br />»»»>»»»»»»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY <br />2. SLOPING: <br />3. PIPES: <br />4. HEADWALL: <br />None ❑ Dirty Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ❑ Towards Pavement�j Flat ❑ <br />None G® Existing — Type <br />Other pipes in neighborhood: Yes No Approaches <br />Yes El No 0 IAI <br />5, ASPHALT CONCRETE DIKE: Yes F'1 No <br />6. BARRIERS: <br />7. DITCH <br />along Right -of -Way <br />Yes ❑ No & If Yes: V Style El <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»>»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY; SFR j� Commercial ❑ <br />Paved with _ � <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />"Min Depth A.C. over <br />Agriculture F'1 Industrial ❑ <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />3. HEADWALL: Yes ❑ No <br />4, <br />"Min Depth'/;' A.B, over <br />Ft. and Diameter of Pipe /� <br />No <br />No <br />Total Number of Storm Drain Inlets: <br />inches) <br />PAVED FRONTAGE: Paved with "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 ection <br />Driveway w/ or w/o <br />pipe $140,00 <br />Driveway w/box Culvert $181.00 <br />P'@NCRDACHlAENTSIMostor Fams4ompbieslENCROACHMENT PERMIT DRNEWAY.doc (OWOB) <br />❑Paved Frontage $116,00 + 0.531ft, <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />