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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 all 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 an4anytached sh et, i fide s general or special III provisions. <br />6�Qr <br />nature o Annlican Date <br />»»»»»»»»»»»»»»»»»»»»> FI ELD I NSPECTIO N (OFFI C E U SE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ Dirt ❑ Gravel Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING <br />3. PIPES; <br />4. HEADWALL: <br />Away from Pavement � Towards Pavement ❑ Flat ❑ <br />FX <br />None, Existing–Type <br />Other pipes in neighborhood; Yes <br />Yes ElNo (E]5. ASPHALT CONCRETE DIKE: Yes ❑ No ,FX <br />6, BARRIERS; along Right -of -Way <br />No Approaches Cross Drain Size <br />7, DITCH: Yes El No � If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR Z Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over 4— "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: <br />Notes; <br />3. HEADWALL: <br />Length of Pipe Required <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 />inches) <br />4. PA\/ED FRONTAGE: Paved with "Min Depth A,C. over "Min Depth'/4' A.B. <br />Measuring Feet in length and Feet in width <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> > F E E S «««««««««<<<<<< «««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway wl or wlo pipe $1 <br />40,00 <br />Driveway wlbox Culvert $181.00 <br />P.IENCR0.4CHIAENTSIMwsler Forms-TamplalaslEI4CR0,4CHL4EhR PERM'T DRIVEWAY.dw (f8108) <br />Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00+ 1,16/ft. <br />