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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 />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 helshe 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 t daanyattached sheet, included as general or special III provisions. <br />Signature of Applicant Title Date <br />»»»»»»»»»»»»»»»»»»»»>FIELD 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 I Towards Pavement ❑ Flat ❑ <br />3. PIPES: None ❑ Existing—Type of <br />Other pipes in neighborhood: Yes 9 No LJ Approaches LJ Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No & <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />G. BARRIERS: along Right -of -Way <br />7. DITCH: Yes X No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth _ <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR e <br />Notes: <br />2. PIPES <br />Notes: <br />3. HEADWALL: <br />Commercial ❑ <br />Paved with 2 <br />Length of Pipe Required <br />Agriculture ElIndustrial F]"Min Depth A.C. over <br />"Min Depth'/" A.B. over <br />Ft. and Diameter of Pipe �� incli(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 />Yes ❑ No..� <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth 3/" 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 w/o <br />pipe _$140.00 <br />Driveway wlbox Culvert $181.00 <br />P:IENCROAOHMENfSIMas!er Farms-Template!dENCROhCHhIENT PERMIT DRIVEVlAY.doc (08108) <br />Paved Frontage $11G.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16Ift. <br />