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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 Joaquin County Encroachment Permit; and <br />6. That if permissi n is granted as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of%this and an t ched sheet, inc uded as general or special III provisions. <br />Signature of pplicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (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 ❑ <br />3. PIPES; None � Existing—Type <br />Other pipes in neighborhood: Yes 0 No Ll Approaches Lj Cross Drain Lj Size <br />4. HEADWALL: Yes ❑ No <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No Or <br />6, BARRIERS: <br />along Right-of-Wa <br />DITCH <br />y <br />Yes ❑ No FX <br />If Yes; V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ❑ Commercial Agriculture ❑ Industrial ❑ <br />Paved with <br />Notes: <br />Z <br />2. PIPES: Length of Pipe Required <br />Notes: <br />"Min Depth A.C. over 06"Min Depth'/d' A.B. over <br />_ <br />Ft. and Diameter of Pipe <br />To be connected to any adjacent driveway pipe Yes ❑ No L-1Drainage Inlet Required Yes .❑ No ❑ <br />Total Length: 14.1.(with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No ❑ <br />inches) <br />4. PAVED FRONTAGE: Paved with "N}in Depth A.C. over "Min Depth'/q' A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135,00 <br />Field Ins ection <br />Driveway wl or w/o <br />pipe $140.00 <br />Driveway wlbox Culvert $181.00 <br />P:IENCROACHMEIVTSIMsslrr FonaTemplaleslEiJCROACHMEIJT PERMR DRIVEWAY duc (08108) <br />Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft, <br />