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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; It 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 attach shee ncluded as g neral or speci <br />ial III provisions. �7 <br />X <br />Si ha re f Applic t 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.ET Existing—Type <br />Other pipes in neighborhood: Yes Lj No Lj Approaches Lj Cross Drain H Size <br />4. HEADWALL: Yes ❑ No ,2 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No Z <br />7. <br />along Right -of -Way <br />DITCH <br />Yes ElNo 2f If Yes <br />V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: <br />Notes: <br />2. PIPES: <br />Notes; <br />SFR ❑ <br />Commercial K Agriculture ❑ Industrial <br />aved with �"Min Depth A.C. over "Min Depth'/" A.B. over <br />P� <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 />3. HEADWALL: Yes ❑ No ❑ <br />inches) <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 />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:IENCRDACHIdENTS11Aasler Fortns-TemFlateslENCRDACHMENT PERMIT DRIVEWAY.dac (08108) <br />Paved Frontage $116.00 + 0.53/ft. <br />Curb, Gutter, Sidewalk $140.00 + 1.16/ft. <br />