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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 />indicatedjatte <br />an Joaquin County Encroachment Permit; and <br />6. That if ped requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this ane ,included as general or special IIIprovisions. <br />/oe1�c /o( <br />nature of Applicant Title I fate <br />»»»»»»»»»Fl ELD I NSPECTION (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 it bf <br />3. PIPES: <br />4. HEADWALL: <br />6. BARRIERS: <br />None Existing—Type, <br />Other pipes in neighborhood <br />Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes N014 <br />❑ <br />along Q! Ml <br />DITCH: <br />Yes ElNo Z If Yes: V Style El <br />es � � gross uratn <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR jr 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 <br />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 ber of Storm Drain Inlets: <br />inches) <br />3. HEADWALL: Yes ❑ No� <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C, over " Min Depth 3/4' A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««G««««««««««««««««««< <br />Driveway Encroachment Permit base fee $135.00 >WZ,lS <br />r <br />LA <br />Fie Ins ection <br />Driveway wl or w/o pipe $140.00 <br />Driveway w/box Culvert $181.00 <br />PIENCROACHMIEIJTSIidasler Forms-TempleleslENCROAChIMENT PERMIT SRI\'EWAY.doo (08108) <br />Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />