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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 ttach eet included as general or special III provisions. <br /> X 12 Z©( <br /> Signa re o Title I Dater <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> }� EXISTING CONDITIONS <br /> 1. DRIVEWAY: None g' Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Existing—Type <br /> 0th es in neighborhood_.-_Ye_s7LJ No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ Nok <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ NO�, lf Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture Industrial ❑ <br /> ,�aved with /— "Min Depth A. .over "Min Depth Y<"A.B.over <br /> Notes: 5' <br /> 2. PIPES: Length of Pipe Required ✓ Ft.and Diameter of Pipe / inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Tot; <br /> ot Number of Storm Drain Inlets: <br /> Notes: �— <br /> 3. HEADWALL: Yes ❑ NoK <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 /> i d Inspection <br /> AI,LDriveway w/or w/o pipe $121.00X L ) ❑ Paved Frontage $116.00+0.53/ft. <br /> El Driveway w/box Culvert $181.00 Curb,Gutter,Sidewalk $121.00+1.16/ft. <br /> M.ICENTRALSERNCESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (09/13) Page 2 of 2 <br />