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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 ermission is granted as-reque9ted, he agrees to do the work described in accordance with all terms, condition and restriction <br />oft ' an ny he induogd as general or special III provisions. <br />Signature of Applicant Title u8te <br />»»»»»»»>»»»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None X Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement X Flat ❑ <br />3. PIPES: None Existing — Type <br />Otheripes in neighborhood: Yes No Approaches LJ Cross Drain 0 Size <br />4. HEADWALL: Yes ❑ No <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ Nox If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»>»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR X Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over 4 "Min Depth 3/4' A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Notes: <br />Ft. and Diameter of Pipe N <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No lk <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No PV <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 />inch(es) <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />Field Inspection <br />Driveway w/ or w/o pipe $121.00 Paved Frontage $116.00 + 0.53/ft. <br />Driveway w/box Culvert $181.00 HCurb, Gutter, Sidewalk $121.00 + 1.16/ft. <br />M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT DRIVEWAY.DOC (09113) Page 2of2 <br />