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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. granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and any ched sheet,included s ge al or special III provisions. <br /> r i <br /> Signature pp is nt itle ate <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 <br /> Pavement ❑ Flat <br /> 3. PIPES: None ❑ Existing–Type I,C,44r�I <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain ❑ Size !� __ <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE:.Yes ❑ No k <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ff— No ❑ If Yes: V Style ❑ 2 Point &I Other ❑ Width –�— Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERM ITS PEQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial �k Agriculture ❑ Industrial <br /> Paved with "Min Depth A.C.over "Min Depth 1/4'1 A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes E] No <br /> g <br /> Total Length: (with proposed)ro Total Number of Storm Drain Inlets. <br /> ) <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No� <br /> "Min Depth A.C.over "Min Depth'A"A.B. <br /> 4. PAVED FRONTAGE: Paved with length and Feet in width Feet in len <br /> Measuring g <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $135.00 <br /> Field Inspection 121.00 <br /> Driveway w/box Culvert $ HCurb, <br /> Paved Frontage $116.00+0.53/ft. <br /> Driveway w/or w/o pipe $18100 Gutter,Sidewalk $121.00+1.16Ift. <br /> __—.____._._.,,...,.,, .,�....,�..ncr�oocruronnrueeonrroconrnon�nrevnnr mofizi <br />