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THE APIPUCAN i;HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application and that the description included in this application are coned to the best of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified tD represent the owner;and . <br /> 3. That he/she wig assume full responsibility for all liability for persona,injwy or damage to property which may arise out of the wrack <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 shag defend,indemnify and hold them and each of them Harmless for such claim;and <br /> 5. That work shag 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 any attached sheet,inchided as general or special III provisions. <br /> 4K W -'✓ <br /> Signature of Applicant Title - ate <br /> »»»»»»»»»»»»»»»»»>»»»»FIELD IN5PECT.ION C0MW ITS««<<««««««««««««««««««< <br /> EXISTING CONI11 IONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: NoneExisting—Type <br /> Other E in neighborhood: Yes No Y lie Approaches U Cross Drain 0 Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ Nok <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes E] No/0If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»»»»»»»»>>tt��»»»>»»»»»»>PERMITS REQU REAENTS«««««««««<««<z«««t<««««< <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial <br /> Paved with 2 "Min Depth A.C.over_ "Min Depth'14'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 YV A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $100.00 ff 6ry, <br /> Field Ins ction <br /> Driveway w/or w/o pipe $107.00 Paved Frontage $113.00+0.52/ft. <br /> Driveway w/box Culvert $175.00 e Curb,Gutter,Sidewalk 5110:00+1.05/ft. <br /> U\CENTRALSERVICES',CLERICALWUB.SV,WKIWSTER.PS%ENCROACHMENT PERMT ORIVEWAY.000 (10709) Page 2 of 2 <br />