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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 59%nf! <br />grees to do the work described in accordance with all terms, condition and restriction <br />of this neral or special III provisions. <br />Z . zi <br />Signajafe of Applicant Title Date <br />»»»»»»»»»>»»»»»>»»»»»>FIELD INSPECTION (OFFICE USE ONLY)«««««««««««««««««<<<< <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None X Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None Existing — Type <br />Otheripes in neighborhood: Yes No Approaches Cross Drain Size <br />4. HEADWALL: Yes ❑ No X <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No An <br />G. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No 0 If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width Depth <br />»»»>»»»»»»»»»»>»»»»»>>>>»»>>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercialk Agriculture ❑ Industrial F1 <br />Paved with Z "Min Depth A.C. over & "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />Ft. and Diameter of Pipe <br />No <br />� <br />No <br />Total Number of Storm Drain Inlets: <br />inch(es) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth '/4" A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»>»»»»»»»»»»»»»»»»>»»FEES ««««««««o ««<«««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00\ <br />Field Ins ection (p <br />NJ Driveway wlorw/opipe $140.00 Paved Frontage $116.00+0.53/ft. <br />Driveway w/box Culvert $181.00 B Curb, Gutter, Sidewalk $140.00 + 1.16111. <br />MNCROACNMEMSIMMbr R.U pblas NCROACNMEM PENMR DRWE AYd (000) <br />