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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. Tha'' iss)o granted as r�qwested. to do the work described in accordance with all terms,condition and restriction <br /> this nd attached sh incl e a e or special III provisions. <br /> /2 -i <br /> Signature o p icant Title Date <br /> »»»»»»»»»»»»»»»»»»>»»»FIELD INSPECTION <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: NoneExisting–Type_ <br /> Other les in neighborhood:—Y—es-0 No Approaches LJ Cross Drain LJ Size <br /> 4. HEADWALL: Yes ❑ N* <br /> 5 ASPHALT CONCRETE DIKE: Yes ❑ No XJ <br /> 6. BARRIERS: along Right-of-Way <br /> 7, DITCH: Yes ❑ NohN If Yes: V Style ❑ 2 Point ❑ Other'❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIRErAEN T S««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial Agriculture ❑ Industrial �� <br /> Paved with �_"Min Depth A.C.over'Min Depth%`A.B.over <br /> Notes; <br /> 2. PIPES: Length of Pipe Required &1A Ft.and Dia er of Pipe n 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 /> fits <br /> Driveway Encroachment Permit base fee $135.11 <br /> F'e d Inspection <br /> Driveway wl or uilo pipe $121.0 Paved Frontage $116.00+0.531ft. <br /> Driveway w/box Culvert $181,00 ❑ Curb,Gutter,Sidewalk $121.00+1.16/ft. <br /> M.(CENTRAISERVICESVCLERICALPU9-SV,WK4-(ASTER.P&ENCROACHIJENTPERMIT DRIVEVVAY.DOC (09113) Page2of2 <br />