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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(hbr knowledge; and <br />2. Thatrbplshe 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 p}operty4hidhmay;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 />indicatedsite.wlth valid,$gn. paquitl CountyEncroachment Permit; and <br />6. That if permission is granted as re�g�uu d he qgrees to do the work described in accordance with all terms, condition and restriction <br />of this and any att ehe '$fret" q aS' eneral or special III provisions. <br />/Z� <br />StgrfaLure of AppTiicant Title Uge <br />»»»»»»»»»»»»>»»»»»>»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base e Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement � Towards Pavement ❑ Flat ❑ <br />3. PIPES: None �xist)ng'=Type <br />Other pipes in neighborhood: Yes No LJ Approaches <br />4, HEADWALL: Yes ❑ NoeEr <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No V <br />IfYes: VStyle ❑ 2Point ❑ Other ❑ Width Depth <br />»»»»»»»»>»>»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z Commercial ❑ Agriculture ❑ Industrial ❑ <br />Notes: <br />2. PIPES: <br />Notes: <br />Paved with Z "Min Depth A.C. over 4 "Min Depth %;' A.B. over <br />Length of Pipe Required �� Ft. and Diameter of Pipe ,/x/]a inch(es) <br />To be connected to any adjacent driveway pipe Yes El <br />No [� , <br />DrainagelnletRequired Yes ❑ No [�` <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ Na <br />J <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth'/," A.B. <br />Measuring Feet in length and Feet in v4dth <br />»»»»»»»>»»>»»»»»»»»»»»»»»»»»FEES ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Field Ins ection <br />Driveway wl or w/o pipe $140.00 <br />Drivewayw/box Culvert $181.00 <br />X NCRNFCNAIENiSlWvler Fams7e"le105lENLRMCHM1FMPERAVf ONNE44NVAoo(OBAe) <br />Frontage <br />$116.00+0.53/ft. <br />ePaved <br />Curb, Gutter, Sidewalk <br />$140.00+ <br />1.16/ft. <br />. <br />