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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 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 this and any attached sheet, included as general or special III provisions, <br />1.�1P fit" c7 Jril o f (Jir7 �f � dr -r ir-x?a <br />Signature of ADDlicant 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 ❑ Towards Pavement ❑ Flat <br />3, PIPES; None k <br />Existing =Type <br />Other pipes in neighborhood: Yes No Approaches Ll Cross Drain Size <br />4. HEADWALL: Yes ❑ No ir <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS; <br />7. DITCH: <br />along Right -of -Way <br />Yes ❑ No og If Yes: V Style El <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERM ITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ,91 <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over _ "Min Depth '/4" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />Notes: <br />To <br />Ft. and Diameter of Pipe /�/ <br />No <br />No <br />ial Number of Storm Drain Inlets: <br />inches) <br />3, HEADWALL: Yes ❑ No <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth %" A.B, <br />Measuring Feet in length and Feet in width <br />»»»»»»»>»»>»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Encroachment Permit base fee $13 <br />wl or w/o <br />P:IENCROACHMEp751Master Farms-TemplaleslENCROACHMEM PERMR CRIVEWAY.dac (08108) <br />40;00 ❑Paved Frontage $116,00 + 0.53/ft. <br />Curb, Gutter, Sidewalk $140,00+ 1.161ft, <br />