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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 permission is granted as req ested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and anyqttached sheet, incl ded as general or special III provisions. <br />XSignature of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good)AZ <br />❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None Existing—Type <br />Oth pipes in neighborhood: Yes Lj No6f I Approaches H Cross Drain Size <br />4. HEADWALL: Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No it <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No Ve If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR C] Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 02?� "Min Depth A,C, over "Min Depth Y4" 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 <br />No <br />No� <br />Total Number of Storm Drain Inlets: <br />inches) <br />3. HEADWALL: Yes ❑ No f� <br />4. PAVED FRONTAGE: Paved with "Min Depth A,C. over " Min Depth 3/d' A, B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEESa«««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway w/ or w/o <br />pipe $140,00 <br />Driveway wlbox Culvert $181.00 <br />P:IENGROACHIAEMSVAasler Farms-TamplateslEIJCROACHNEM PERMR ORIVEWAY.dx (08/08) <br />®Paved Frontage $116,00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140,00 +'1.161ft. <br />