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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this Win,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/fter 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,of AW or employee <br /> thereof,he shall defend;indemnify and hold them and each of them hamdess for such cairn;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 anattached s t,included as general or special III provisions:. <br /> MUM Title Date <br /> »»»»»»»»> >>>>> »»»»»> FIELD It11SPECT{�1 COMMENTS«««««««««««<«««««««««« <br /> EXISTING CORS <br /> 1. DRIVEWAY: None Dirt ❑ Graver Aggregate Base ❑ Paved(poor)❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards PavementX Fla <br /> 3. PIPES: None W Existing—Type a <br /> Ot in neighborhood: Yes Na Approaches LJ Cross Drain Li 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 X 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»PERNTS REOWREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR W Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth 3/."A.S.over <br /> Notes: 4al"I�n <br /> 2. PIPES: Length of Pipe Required '� Ft.and Diameter of Pipe /Z inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No Al <br /> Total Length: / (with proposed) 4Total Number of Storm Drain Inlets: <br /> Notes: 4ffW �'17 <br /> 3. HEADWALL: Yes ❑ Nok <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 /> Driveway Encroachment Permit base fee $85.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe $95.00Paved Frontage $100.00+0.46/ft. <br /> Driveway w/box Culvert $155.00 H Curb,Gutter,SSdewak $100.00+0.98/ft. <br /> M:VCEWRALSERVICES%CLEPJCALIPUB-SV.VO(W STER.P$%ENCROACHMENT PERMIT ORNEWAY.DOC (0108) Page 2 of 2 <br />