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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 permission is granted as requested tie agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any attach sheet, Inc ed general or special III provisions. <br />Signature of Applicant Title Date . <br />»»»»»»»»>»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt d Gravel ❑ Aggregate Base ❑ PavPtl (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br />3. PIPES: None V Existing—Type <br />Other pipes in neighborhood: Yes LJ No LJ Approaches Cross Drain U Size <br />4. HEADWALL: Yes ❑ No [Z <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No [2j <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No [/ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>»»>»»»»»»>,»u--�,sr»»>»>»»»»»»»»»>PERMITS REQUIREMENTS«««««««««««««««««««« <br />1, DRIVEWAY: SFR « <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over t <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />1 "Min Depth %<" A.B. over <br />Ft. and Diameter of PipeLA <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 />inches) <br />3. HEADWALL: Yes ❑ No [� <br />4. PAVED FRONTAGE: Paved with 9_ "Min Depth A.C. over Li " 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 <br />w/or w/o pipe $140.00 a PavedFrontage $116.00+0.53/(l. <br />Driveway w/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00 + 1.16/tt. <br />XWNMOAWeEvrrsu.HnxFw, TeNWN ENMMCHWWPv TDMMAraoo(00) <br />