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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 />G. That if permission is granted as requ ted, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any att ched sheet, inc d as general or special III provisions, <br />Signature ofApplicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««<a«««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ Dirt ❑ Graver Aggregate Base F1 Paved (poor) El Paved (good) ❑ <br />2. SLOPING: Away from Pavement E] Towards Pavement ❑ Flat/1[J <br />3. PIPES: None P. Existing —Type �`� <br />Other pipes in neighborhood: Yes No Approaches Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No IL <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: <br />7, <br />along Right -of -Way <br />DITCH <br />Yes [l No If Yes: V Style ❑ <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERR4ITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY <br />Notes: <br />2, PIPES: <br />Notes: <br />SFR X Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 1/ "Min Depth A.C. over if <br />Length of Pipe Required <br />"Min Depth 3/4' A.B, over <br />Ft. and Diameter of Pipe <br />To be connected to any adjacent driveway pipe 'Yes ❑ No y � <br />Drainage Inlet Required Yes ❑ No <br />Tota( Length: (with proposed) Total Number of Storm Drain Inlets: <br />inches) <br />3, HEADWALL: Yes ❑ No <br />4. PAVED FRONTAGE: Paved "Min Depth A,C, over " Min Depth %" A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135,00 <br />Field Insuection ' <br />Driveway wl or w/o pipe $1 <br />40.00 <br />Driveway w/box Culvert $181,00 <br />P:164CROACHNEFIiSIA04slzr Fomes-TemplaleslENCROACH(JEMT PERMIT ORIVEWhY.doa (08/00) <br />❑Paved Frontage $116,00 + 0.53/ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.161ft. <br />