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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 />Z. 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 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 spec! 1-111 provisions. <br />1tv fz <br />wv, �o / <br />SignaturEf of A plicant Title ate <br />»»»»»>>>>»»»»»»»»»»»»»> FI ELD 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 12:* Cvr/u Veal <br />Other pipes in neighborhood: Yes No Approaches Cross Drain LJ Size 14 <br />4, HEADWALL: Yes ❑ No 4K <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes [L No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ftL. Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over 9' "Min Depth %" A.B. over <br />Notes: <br />2, PIPES: Length of Pipe Required Ft. and Diameter of Pipe 1120 m4i inch(es) <br />To be connected to any adjacent driveway pipe Yes ❑ No [� <br />Drainage Inlet Required Yes ❑ No �( <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth 1/4" 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 wlo pipe $140.00 <br />Dnveway wlbox Culvert $181.00 <br />P:IENCROACHMEHTSIM.gsler FonnsTemplaleslEPICROACHI,!ENT PERMR DRIVEWAY dm (08188) <br />❑Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />