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THE APPLICANT h-IEREBY 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, oris 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 requ ted, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and an attached sheet, inclu d as general or special III provisions. <br />Signature of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY <br />2. SLOPING: <br />3, PIPES: <br />4, HEADWALL: <br />None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) <br />Away from Pavement ❑ Towards Pavement � Flat ❑ <br />None f � Existing -Type <br />Other pipes in neighborhood: Yes <br />Yes ❑ No �' <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No <br />Paved (good) ❑ <br />No Approaches Cross Drain Size <br />6, BARRIERS: along Right -of -Way <br />7, DITCH: Yes ❑ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»>»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR � Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with �. "Min Depth A.C. over �_ "Min Depth'/4' A.B. over <br />Notes: � ('� f �rU C f' <br />2. PIPES: <br />Notes: <br />r <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 />Yes ❑ No ❑ <br />inches) <br />4. PAVED FRONTAGE; Paved with "Min Depth A,C, over " Min Depth'/4' A.B. <br />INeasuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee yam.- $135,00 <br />Field Ins ection <br />Driveway wl or w/o pipe, <br />Driveway w/box Culvert_ <br />$140.00 <br />$181.00 <br />P:IENCRCAf.HMENT5Vvlasler Forms-TemplataslEPlCP,OACHME�T PERMR DRIVEWAY.doo (OBIOB) <br />ePaved Frontage $116,00 + 0,531ft, <br />Curb, Gutter, Sidewalk $140,00+ 1,161ft. <br />