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THE APPLICANT HERESY CERTIFIES: <br /> 1. <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 permis on is)ranted as requesed a agrees to do the work described in accordance with all terms,condition and restriction <br /> OL th%and an attac d sheet,includecL general or special III provisions. <br /> Sign tG of Ap lican Date <br /> »»»»»»»»»»»»»»>>-»»»»>(»> I5 D INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate BAa ase ❑ Paved(poor) Paved(good) El2. SLOPING: Away from Pavement ❑ Towards Pavement/ Flat ❑ <br /> 3. PIPES: None�] Existing-Type <br /> Other pi sin neighborhood: Yes No Approaches Cross-Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE:.Yes ❑ No t <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No Pd If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»>»»»>;»j»»»»»»»>»»»»»>PEPMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial [_ Agriculture ❑ Industrial <br /> ❑ <br /> Paved with 2- "Min Depth A.C.over t0 "Min Depth 3/4'A.B.over ` I ^ <br /> Notes: <br /> 6 e (� � i vi AJU) .b w(W W �C�- �'C <br /> 2. PIPES: Length of Pipe Required Ft.and Dia eter 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) 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'/<"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 Paved Frontage <br /> $116.00+0.53/ft. <br /> Driveway wl or w/o pipe $121.00 HCurb, <br /> gDriveway wlbox Culvert $181.00 Gutter, Sidewalk $121.00+1.16/ft. <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (09113) Page 2 of 2 <br />