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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 /> hisfiter 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 an ny attached stet,included as general or special III provisions. <br /> Regulatory Specialist 08/05/2015 <br /> Signature of Applicant Title Uate <br /> Peter Dean,Repulatory Specialist <br /> »»»>»»»»»»»»»»»»»»>>>>>>FIELD INSPECTION(OFFICE USE ONLY)««««««««««««««««««« <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None j4 Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat r <br /> 3. PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes o U Approaches LJ Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No if <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)d14J Other ❑ Width Depth <br /> »»>>>>>>>'»»»»»»»»»»»»»»>»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commerotal W Agriculture ❑ Industrial <br /> ❑ <br /> Paved with "Min Depth A.C.over CGS "Min Depth'/."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 16 <br /> Drainage Inlet Required Yes ❑ NoAff <br /> Total Length: (with proposed) Tota 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«««««««««««««««««««««<c««««« <br /> Driveway Encroachment Permit base fee @ $135.00 Total = $256.00 <br /> Field Ins esti n <br /> Driveway w/or w/o pipe 1 @ $121.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $181A0 B Curb,Gutter,Sidewalk______$121,00+1,16/ft. <br /> xtENG20."p1YFNt5Ukxka scrm,r«rd.r'ENatoM1crrre ct-aa5�,ry.��nry me(Ce,,g61 <br />