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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 valid San Joaquin County Encroachment Permit; and <br />6. That if permiss' is granted as request agrees to tlo the work described in accordance with all terms, condition and restriction <br />of this and a attached sheet in rat or special III provisions. <br />>»»»»»»»»»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑ <br />3. PIPES: None ❑ Existing — Type <br />Other pipes in neighborhood: Yes No Ll Approaches LJ Cross Drain Size <br />4, HEADWALL: Yes ❑ No ❑ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No ❑ <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»>»>»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required Ft. and Diameter of Pipe <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 />3. HEADWALL: Yes ❑ No ❑ <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depih %" 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 w/ or w/o pipe $140.00 <br />Driveway wlbox Culvert $181.00 <br />XIENLftOACHMEMSVAasie, Fams4anplalealEN00.0gC WAENT PERMR DRIVEWAY tloo (OBroB� <br />8 <br />Paved Frontage <br />$116.00 <br />+0,53/ft. <br />Curb, Gutter, Sidewalk <br />$140.00 <br />+ 1.16Ift. <br />