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THE APPLI.CANT,: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 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 />elk �0 ' CE I2�3o`2O2� <br />Signature oT PoplrOant Title Liate <br />>»»»»»»»»»»>»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) [J] Paved (good) ❑ <br />2. SLOPING: Away from Pavement 91 Towards Pavement ❑ Flat ❑ <br />3. PIPES: None'; _ Existing—Type <br />Other pipes in neighborhood: Yes LLj No L.J Approaches Cross Drain Li Size �" <br />4. HEADWALL: Yes ❑ No ✓ <br />5. ASPHALT CONCRETE DIKE: Yes E] No d <br />6. BARRIERS: <br />7. DITCH <br />along--Right-of-Way <br />Yes [A No ;_ If Yes: V Style El2 Point ❑ Other ElWidth <br />Depth <br />»»»»»»»»»»»»»»»»>»»»»»»>»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR d Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over L <br />1 "Min Depth %;' A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe �2" inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No EJ <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth %P A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»>»>» »»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Field Ins ection <br />Driveway w/ or w/o pipe $140.00 Paved Frontage $116.00 + 0.53/111 <br />Driveway w/box Culvert $181.00 a Curb, Gutter, Sidewalk $140.00 + 1.16/0. <br />X NC CHMFMWasWf Fa T"W0 ENCRCACHNFNrP PWT DWMATtlwWM) <br />