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THE APPLICANT HEREBY CERTIFIES: <br />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 properly 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 [hem 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 Sa9*aquin County Encroachment Permit; and <br />6. That If permission is r� 6d As requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any at h �t neluded asgeneral or special III provisions. <br />11/29/22 <br />Sign ure of Applicant Title Date <br />»»>»»»>»»»» »» >>>>>>»»»»FIELD INSPECTION(OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS / <br />1. DRIVEWAY: None 171 Dirt [I Gravel El Aggregate Base El Paved (poor) El Paved (good) Ig <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 171 <br />3. PIPES: <br />None ❑ Existing—Type <br />2 - o&r of v it�id. le 46" 'a i <br />Other pipes in neighborhood: <br />Yes No proaches Cro s Drain Size 3 6'� <br />4. HEADWALL: <br />Yes Ef No ❑ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />jr <br />6. BARRIERS: <br />along Right -of -Way <br />7. DITCH: <br />Yes [A No ❑ If Yes: V <br />Style ❑ 2 Point ❑ Other ❑ Width Depth <br />>>>»»»>»»»»»»>»»»»»>»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: <br />SFR ❑ Commercial M <br />Agriculture ❑ Industrial ❑ <br />Paved with 2 <br />"Min Depth A.C. over b "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: <br />Length of Pipe Required <br />Ft. and Diameter of Pipe 1 0 inch(es) <br />To be connected to any adjacent driveway pipe Yes eNo ❑ / <br />Drainage Inlet Required <br />Yes 171No [/]" <br />Total Length: <br />(with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes Pr No ❑ <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth''/," A.B. <br />Measuring Feet in length and Feel In width <br />>>>»»»»»»>>»»»»»»»»>>>>»»»»»»»»> F E E S ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Field Ins ection <br />Ddveway wl or w/o pipe $140.00 <br />Driveway wlbox Culvert $181.00 <br />k1FNGOkIWVUR%Uslee F" Tem les� KWff Dp AYd PM <br />Paved Frontage $116.00 + 0.53111. <br />Curb, Gutter, Sidewalk $140.00 + 1.16/0. <br />