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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 liaty 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 terms, condition and restriction <br />of this 54 any attached s pet, included as general or special III provisions. <br />9- 3D-2dLo <br />Sign ure of Appli nt Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY <br />2, SLOPING <br />3. PIPES: <br />4, HEADWALL: <br />None Dirt ❑ Gravel ❑ Aggregate Base <br />Away from Pavement ❑ Towards Pavement ❑ <br />None � Existing —Type <br />Flat <br />Other pipes in neighborhood <br />Yes F1 No <br />❑ Paved (poor) ❑ <br />Paved (good) ❑ <br />Yes <br />No <br />Approaches <br />Cross <br />Drain <br />Size <br />5, ASPHALT CONCRETE DIKE; Yes E] No <br />6. BARRIERS; <br />7. <br />along Right -of -Way <br />DITCH <br />Yes ElNo xIf Yes: <br />V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»>»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFRI Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 20*� "Min Depth A.C. over "Min Depth %" A.B. over <br />Notes: <br />2, PIPES; <br />Notes: <br />Length of Pipe Required <br />Ft, and Diameter of Pipe <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total N ber of Storm Drain Inlets: <br />3, HEADWALL: Yes ❑ <br />4. PAVED FRONTAGE: <br />Paved with <br />Measuring <br />"Min Depth A.C. over <br />Feet in length and _ <br />"Min Depth'/<" A.B. <br />=eet in width <br />inches) <br />»»»»»»»»»»»>»»»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $,135.00 e <br />Field Ins ection <br />r)veway w/ or w/o pipe $140,00 <br />Driveway w/box Culvert $181.00 <br />P:IENCRDACHMENTSIMaster Farms-TemplaleslENCRDACHMENT PERMIT DRIVEWAY.doo (OBNB) <br />❑Paved Frontage $116.00 + 0.53/ft. <br />Curb, Gutter, Sidewalk $140,00 + 1.161ft, <br />