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THE APPLICANT HEREBY CERTIFIES: <br />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, inclu general or special III provisions, <br />nature p t Title t• <br />»»»»»»»»»»»»»»> >»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br />EXISTING CONDITIONS <br />DRIVEWAY <br />2. SLOPING: <br />3. PIPES: <br />4. HEADWALL: <br />None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) <br />Away from Pavement f4, Towards Pavement ❑ Flat ❑ <br />None to Existing — T <br />Other pipes in neighborh <br />Yes ❑ No E� <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No X <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No M If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR P Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over "Min Depth %- A.B. over <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />Ft. and Diameter of Pipe <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 />3. HEADWALL: Yes ❑ No ;9 <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 Ins ection <br />Driveway w/ or w/o pipe �r. $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.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (09/13) Page 2 of 2 <br />