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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 by <br />County Encroachment Permit; and <br />6. That if permon is granted as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and anyissiattached sheet, included as general or special III provisions. <br />Tcahal laPPrai ra 3/8/24 <br />Signature of Applicant Title ate <br />»»>»»»»»»»»»>»»»»»»>»FIELD INSPECTION (OFFICE USE ONLY)<c<c«««e<e««««««<e<e«<c«cc< <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel 1 Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None Existing—Type <br />Other pi es in neighborhood: Yes No Approaches LJ Cross Drain Size <br />4. HEADWALL: Yes ❑ No 0 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No 9 If Yes: VStyle ❑ 2Point ❑ Other ❑ Width Depth <br />»»»>»»»»»>»»»»»»>»»»» »»»»>PERMITS REQUIREMENTSc«<c««c«<e<e«e«««cc«e<cc«cc«e« <br />1. DRIVEWAY: SFR X Commercial ❑ Agriculture ❑ IndustrialE]2 <br />Paved with "Min Depth A.G.ACover "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 driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No 14 <br />Total Length: (with proposed) Total Numberof Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No [/] <br />4. PAVED FRONTAGE: Pavedwith"Min Depth A.C. over " Min Depth''%" A.B. <br />Measuring Feet in length and Feet in width <br />»»»>»»»»»»»»>»»»>»>»>»»>»>»»»»>FEESeeee<eee««e<e««««<e««««<c<c««««««««< <br />Driveway Encroachment Permit base fee $140.00 <br />F Ins action <br />Driveway w/or w/o pipe $1140.00 BPaved Frontage $116.00+0.63/ft. <br />Driveway w/box Culvert $181.00 Curb, Gutter, Sidewalk $140.00+ 1.16/ft. <br />%tENL OWWUff famcimµYeH3WY1OVJMT ff TDPrvEWRYOn,") <br />