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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 t'ne owner;and <br /> 3. That he/she will assame full responsibility for all liability for persona;injury or damage to property which may arise out of the woric <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 permissio is g nt as nested,he agrees to do the worl,:described in accordance with all terms,condition and restriction <br /> of this and any ach t S. uded as general or special IIi provisions. <br /> Signature o pp i nt'ti#le at <br /> »»»»>»»»»>5»>>»»»>>>>y»»»»>FIELC3INSPECTION COIIAMEt TS<<««<¢««««<<<«<d««««««a<{««< <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: NoneExistingType <br /> Otherklpiofn nei 1) orhood: Yes No H Approaches Cross Drain _ Size <br /> 4. HEADWALL: Yes ❑ NJ( <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> B. BARRIERS: along Right-of-*Vv _ <br /> n <br /> 7. DITCH: Yes Q Nof Yes: V Style ❑ 2 Point ❑ Other [I Width Depth _ <br /> »»»»»»»»»»»»»»»>>>>>a»»»»»»PERMITSiREQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial CAgriculturs ❑ Industrial <br /> Paved with 7 "Min Depth A.C.over "Min Depth%'A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent dr i eway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No . <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over 'Min Depth W A.B. <br /> Measuring Feet in length and Feet in width <br /> Driveway Encroachment permit base fee,____ $135.00 <br /> Field Inspection _ <br /> Ddveway 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+1.16/ft. <br /> ,%iCEFnPAgSEMCESaERICAIIPUMV.4VKiAASTER.PStENCROACIiMEWrPERMJTDRWCWAY.DOC (05713) Page 2of2 <br />