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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 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 atfachecy4eetjncl ded as general or special III provisions. <br /> Signature,of Applicant Title Date <br /> »»»»»»»»»»»»>»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <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 �J <br /> Other ipes in neighborhood: Yes No LJ Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No& <br /> 5. ASPHALT CONCRETE DIKE:. Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes No ❑ If Yes: V Style ❑ 2 Point 9—Other ❑ Width Depth t <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREM ENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR9 Commercial ❑ Agriculture ❑ Industrial F1�J <br /> Paved with "Min Depth A.C.over 4r "Min Depth 3/4'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 driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: �lJ �'"'tsl i✓� '5�1,0V°1,J ,dacli 11 t /i✓'S � 115>✓� <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth Y4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»>»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $135.00 �� <br /> Field Inspection <br /> riveway 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+1.161ft. <br /> eir�nrronicrninreciri roirni poi ro.cinnwnn erco onouronnrunecnrr oevnnT n�mmiev nnr mmtm n,,,,,n,.� <br />