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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 per ' sion' gran te as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this an any ach d e included as eral or special III provisions. <br /> Signature of Applicant Title U 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 E]/�Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑' Existing—Type <br /> Other pipes in neighborhood: Yes LJ No Approaches LJ Cross Drain L Size <br /> 4. HEADWALL: Yes ❑ No ❑ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No D-" <br /> 6. BARRIERS: along Right-of-Way - <br /> 7. DITCH: Yes ❑ No ❑,If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth'/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: <br /> 3. HEADWALL: Yes ❑ No ❑ <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth'W"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $100,00 <br /> FietD <br /> !eE�e%��'w/ <br /> or w/o pipe $10 .0 Paved Frontage $113.00+0.521ft. <br /> /box Culvert Curb, Gutter,Sidewalk $110.00+1.05/ft. <br /> M:ICENTRALSERVICESICLERICAL'PUB-SVWK`�MASTER.PS�ENCROACHMENTPERMIT DRIVEWAY.DOC (10109) Page 2of2 <br />