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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, 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 />VVGA c \,i C_k N 1,_ 1-9� 23 <br />Signa ure of Applican itle Date <br />»»»»»»»»»»»>»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. <br />DRIVEWAY: <br />None ❑ <br />Dirt ❑ <br />Gravel ❑ <br />Aggregate <br />Base <br />❑ <br />Paved (poor) ❑ <br />2. <br />SLOPING: <br />Away from <br />Pavement <br />JZ Towards <br />Pavement <br />❑ <br />Flat <br />❑ <br />3. PIPES: None ❑ Existing -Type jK �� <br />Other pipes in neighborhood: Yes 4 No LJ Approaches <br />4. HEADWALL: Yes ❑ No ❑ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No ❑ <br />6. BARRIERS: along Right -of -Way <br />Paved (good) [7� <br />7. DITCH: Yes ElNo ElIf Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»>»>»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR PT Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C, over "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />Ft. and Diameter of Pipe <br />To be connected to any adjacent <br />driveway pipe Yes ❑ <br />No <br />❑ <br />Drainage Inlet Required <br />Yes ❑ <br />No <br />❑ <br />Total Length: <br />(with proposed) <br />Total <br />Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No ❑ <br />inches) <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 ` NA �,°% <br />Fi d Ins ection />''II <br />Driveway w/ or w/o pipe $140.00><+- e Paved Frontage $116.00 + 0.53/ft. <br />Drivewayw/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00+1.16/ft. <br />k1ENCRCACHMENiSIMaAer FonnsianptalesTNCNOACHNLNi PERMN CRNEIVAY tl"o( <br />