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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 />24 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 <br />-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 any attached sheet, included as general or special III provisions. _ <br />ignat e of Ali n Title Date <br />pp <br />»»»»»»»»»»»»»» >>> »»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None E]Dirt ❑ Gravel [Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat [� <br />3. PIPES <br />4. HEADWALL: <br />None [> Existing — Type <br />Other pipes in neighborhood Yes Ll <br />LTJ <br />Yes ElNo <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No [''f <br />No Approaches Cross Drain Size <br />If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»» »»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z� <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />"Min Depth A.C. over "Min Depth'/" A.B. over <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />Ft. and Diameter of Pipe � <br />No � <br />No V <br />To <br />3. HEADWALL: Yes ❑ <br />4. PAVED FRONTAGE <br />Paved wiih <br />Measuring <br />"Min Depth A.C. over <br />Feet in length and <br />Number of Storm Drain Inlets: <br />"Min Depth 3/" A.B. <br />=eet in width <br />inches) <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Ins ection <br />Driveway w/ or w/o pipe $1404 <br />00 <br />Driveway wlbox Culvert $181.00 <br />P:IENCROACHAIENTSNiasL=r Fertns-TemPlaleslENCRUACHMEM PERMIT URIVEINAY.dac (88108) <br />❑Paved Frontage $116.00 + 0.531ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.1GIft. <br />