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THE APPLICANT HEREBY CERTIFIES: 1. That he/she has read all (he provisions of this application, and that the description Included In this application are correct to the best of hislherknowledge; and 2. That he/she is the owner of the respective property, or is qualified to represent the owner; and 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 described above, or which may arise out of his/her failure to do the work provided herein; and 4. Thal in the event any claim of such liability is made against the County of San Joaquin or any deParlment, official or employee thereof, he shall defend, Indemnify and hold them and each of them harmless for such claim; and S. That work shall be performed by the applicant and/or any representative of the application in the County Right-oFWay at the above Indicated site with a valid San Jo County Encroachment Permit; and 6. That If permissio ranted as r sated, he agrees to do the work described in accordance with all terms, condition and restriction of ihis and ached s da d as general or special III provisions. ------ 9' z -z3 >>>>»»>» >>>»»»>»»»»>»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««<<<<««««««« EXISTING CONDITIONS 1. DRIVEWAY: None ❑ Dirt j`j Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 3. PIPES: None El Existing—Type 211 r"_aiu ced M0 -W Other pipes In neighborhood: Yes No U Approaches Cross Drain Size 4. HEADWALL: Yes ❑ No 4 5. ASPHALT CONCRETE DIKE: Yes ❑ No W 6. BARRIERS: along Right -of -Way 7. DITCH: Yes No ❑ If Yes: VStyle ❑ 2Point ❑ Other ❑ Width Depth »»»»» »»>>>>>,....>>>>>>>>>»»>»»»»»>>>>PERMITS REQUIREMENTS««««««««««««««««««««« 1. DRIVEWAY: SFR Iql Commercial ❑ Agriculture ❑ Industrial ❑ Paved with "Mtn Depth A.C. over _ "Min Depth %" A.B. over Notes: 2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe Inch(es) To be connected to any adjacent driveway pipe Yes ❑ No Drainage Inlet Required Yes ❑ No Total Length: (with proposed) Total Number of Storm Drain Inlets: Notes: 3. HEADWALL: Yes ❑ NoA� 4. PAVED FRONTAGE: Paved with "Min Depth A.G. over "Min Depth 3/." A.B. Measuring Feet in length and Feet in width »»»»»>»»»»»»»»»>»»»»»»»»»»»»FEES ««««««««««««««««««««««««««« Driveway Encroachment Permit base fee $140.00 Id ns action Driveway w/ or Wo pipe $140.00 -Driveway wlboxCulvert $181.00 xitirnonniuurtsrmarmwruM•xeu�rnwrJuuxrrtwrtonrnwnrexroan) BPaved Frontage $116:00+0.5311(, Curb, Gutter,Sidswalk $140.00+1.16/n.