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THE APPLICANT HEREBY CERTIFIES; <br />1, That helshe has read all the provisions of this application, and that the description included in this application are correct to the best of <br />hislher knowledge; and <br />2, That helshe 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 hislher 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 andlor 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 n cfied shee,�cluded as general or special III provisions, <br />ignature of Applican Tit e � Daft <br />»»»>»»»»»»»»»»»»»»»»» FI ELD I NSPECTIO N (OFFI CE U SE ONLY)«««««««««««««««<<««« <br />EXIS I INC CONDITIONS <br />1. DRIVEWAY: <br />2, SLOPING: <br />3, PIPES: <br />4. HEADWALL: <br />None � Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ,� Towards Pavement ❑ Flat ❑ <br />None Existing—Type <br />Other pipes in neighborhood; Yes <br />Yes ❑ No <br />No Approaches Cross Drain Size <br />5. ASPHALT CONCRETE DIKE; Yes ❑ No (� <br />6. BARRIERS: along Right -of -Way <br />7, DITCH; Yes ❑ No �If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERA4ITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR � Commercial ❑ <br />Paved with 2 <br />Nates: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />Agriculture ❑ Industrial ❑ <br />"Min Depth A.C, over g <br />"Min Depth 3/d' A.B, over <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 Number of Storm Drain Inlets: <br />3. HEADWALL; Yes ❑ No <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth'/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 vvl or w/o pipe $140.00 <br />Driveway w/box Culvert $181.00 <br />P:IEIVCROACHAIENTSM7aslsr Form��TertiplaleslEWCP,CACHNEI� PERMIT ORIVEWAY.doc (00/00 <br />❑Paved Frontage $116.00 + 0.53/ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />