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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 ' luded as general or special III provisions. <br /> Signature of Applica itle Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None [TDirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement Qr Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None [v]� Existing-Type <br /> Other pipes in neighborhood: Yes No U Approaches LJ Cross Drain Size <br /> t <br /> 4. HEADWALL: Yes ❑ No P <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [9-" <br /> , <br /> 6. BARRIERS: along Right-of-Way N/onC <br /> 7. DITCH: Yes [azNo ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width ± Depth /•5 -' <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial g- Agriculture ❑ Industrial ❑ <br /> Paved with 2 "Min Depth A.C.over 6 "Min Depth YV A.B.over <br /> Notes: CDiI /'/h 6vi �1 S.J. Co. STl• nd y. XIO. R-/7 (Illelclvd) <br /> 2. PIPES: Length of Pipe Required 0 Ft.and Diameter of Pipe 0 inch(es) <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 /> Notes: 0 qa /le/r /o r2-// .S'�an�4ri1S 4,- ,10•o a %hJ'7-14AI/ioh / L <br /> lq,41e7 size D�'e�tl�S?l CsP �OCq/�A GI�O,��/PA/h �rDiyl /JrdQOSPp (,►�/idPw�y, SPL �/1oA!s) <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with N "Min Depth A.C.over "Min Depth 3/;'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 w/or w/o pipe $121.00 ❑ Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $181.00 Curb,Gutter,Sidewalk $121.00+1.161ft. <br /> M:ICENTRALSERWCESICLERICALIPUB-SV.WKIMASTERPSIENCROACHMENT PERMIT DRNEWAY.DOC (09/13) Page 2 of 2 <br />