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THE APPLICANT HEREBY CERTIFIES: <br /> t. T* a ie has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> hisAw lwiedge;and <br /> 2. That hese is.the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That ttetshe wilt assume fell responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> descr'Ded above,or which may arise out of his/her failure to do the work provided herein;and <br /> 4. TIW in ffte 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 voork shall be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated ske 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 anyattached sheet,included as general or special III provisions. <br /> Signature of Applicant Title Date <br /> s»»»»y> > »>yy»»> »»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ ' Dirt r Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPMN Away from Pavement[] Towards Pavement ❑ Flat <br /> 3. PIPES: None Exists 'Type roaches Cross Drain Site <br /> 11her p in neighborhood; Yes No App <br /> 4. HEADWALL: Yes ❑ No,k <br /> 5. ASPHALT CONCRErE[NICE: Yes 0 No <br /> 6. BARRIERS: along Right-Of-Way <br /> 7, DITCH,: I Yes ❑ No if Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >y»>»»>?»>>>>y»»>»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1 DRIVEWAY: SPR Commercial ❑ Agriculture ❑ Industrial <br /> -Min over <br /> "Min Depth 3/e"A.B.over <br /> Paved with � Min Depth A.C.o <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 /> Drayage 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 <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»>ss»»»»»»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachrnent Permit base fee $90.00 �! 40 <br /> F Driveway wlbox Cuh�rt 2. Paved Frontage $108.00+0.50/ft. <br /> ri+reway w/or w/o pipe. $102.00 ❑ Curb,Gutter,Sidewalk $105.00+1.03/ft. <br /> WMASS TSWLATEMD00AMAW POW WWWAYAC(0808) <br />