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THE APPLICANT HEREBY CERTIFIES: 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 his/her knowledge; and 2. That he/she is the owner of the respective property, or is qualified to represent the owner; and 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 described above, or which may arise out of hislher failure to do the work provided herein; and 4. That in the event any claim of such liability is made against the County of San Joaquin or any department, official or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; and 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 indicated site with a valid San Joaquin County Encroachment Permit; and 6. That if permission is granted as requested, hgagrees to do the work described in accordance with all terms, condition and restriction of this and any attar sfieet, included s as or special III provisions. Signat e of Applicant Title Date »»>»»>»»»»»»»»>»>»»»»»>FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« EXISTING CONDITIONS 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ❑ 3. PIPES: None ❑ Existing — Type Other pipes in neighborhood: Yes ❑ No ❑ Approaches IJ Cross Drain ❑ Size 4. HEADWALL: Yes ❑ No ❑ 5. ASPHALT CONCRETE DIKE: Yes ❑ No ❑ 6. BARRIERS: along Right -of -Way 7 DITCH: Yes ❑ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth »»»»»»»»»»»»»»»»»»»>»>»»»PERMITS REQUIREMENTS««««««««««««««««««««« 1 DRIVEWAY: SFR ❑ Commercial ❑ Agriculture ❑ Industrial ❑ Paved with "Min Depth A.C. over "Min Depth %" A.B. over Notes: 2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe To be connected to any adjacent driveway pipe Yes ❑ No ❑ Drainage Inlet Required Yes ❑ No ❑ Total Length: (with proposed) Total Number of Storm Drain Inlets: Notes: 3. HEADWALL. Yes ❑ Na ❑ inches) 4. PAVED FRONTAGE. Paved with "Min Depth A.C. over "Min Depth %" A.B. Measuring Feet in length and Feet in width »»»»» >»»»»»»»»»>»»»»»»>»»»»>» F E E S ««««««««««««««««««««««««««« Driveway Encroachment Permit base fee $140.00 Field Inspection �.J Driveway wl or w/o pipe $140.00 u Driveway w/box Culvert $181.00 Frontage $116.00 + 0.531ft. BPaved Curb, Gutter, Sidewalk $140.00+ 1.161ft. xeucaoncxnrernsunaner Forms T"Me,UJCROACHMEW aeanO,ir uxivEvav m<(oeroe)