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THE APPLICANT HEREBY CERTIFIES: <br />t. 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 />lli 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 />(S 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 />That work shall be performed by the applicant andlor 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 />J 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 />-D,9-N <br />ignature of Applicant Title Uate <br />>>>>>>>>>> »>» »»»»>»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirtk Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from. Pavement Towards Pavement ❑ Flat ❑ <br />3. PIPES: None ib Existing—Type <br />Other pipes in neighborhood: Yes No Ll Approaches it Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ Nat] <br />S. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes,M No ❑ If Yes: V Style ❑ 2 Point N Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»>» »»»»» >PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFRX Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with G "Min Depth A.C. over "Min Depth 3/4" 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 />Ft. and Diameter of Pipe (L inch(es) <br />No <br />No <br />Total tuber of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ Noy <br />4. PAVED FRONTAGE: Paved with <br />"Min Depth A.C. over " Min Depth 1/4' A.B. <br />Measuring <br />Feet in length and <br />Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135:00 <br />Field Inspection <br />Driveway w/ or w/o pipe $121.00 <br />Driveway Culvert $181.00 <br />Paved Frontage $116.00 + 0.53/ft. <br />w/box <br />Curb, Gutter, Sidewalk $121.00 + 1.161ft. <br />kIBMACHMEMSMmkr.F—Temp'ebo NMOAMMJ PFRWTDNV AVA.(f ) <br />