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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 properly, 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 permissi is granted as r�gpesied, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and ached Kee �h hided as general or special III provisions. <br />� / Z i( <br />Signature of Applicant'Title a <br />»»»>»»>»»»»>»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ Dirt [4 Gravel Rf Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 9 <br />3, PIPES: None [A Existing — Type <br />Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br />4. HEADWALL: Yes ❑ No <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No [Z <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No I If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»>>>>»»»»»»»»>»»»»»>>>>>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR [✓ Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over 4 "Min Depth %" A.B, over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe IVA inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No 11 <br />Drainage Inlet 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 "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 $140.00 <br />Field Ins ection <br />Driveway wlorw/o pipe $140.00e Paved Frontage $116.00+0.531ft. <br />Driveway wlbox Culvert $181.00 Curb, Gutter, Sidewalk $140,00+ 1.16/ft. <br />IENCROACHMEWSW3516ro,ms-TemplaleAENCROACHN.ENT PER MR DRIVEWAVdoo(00180) <br />