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THE APPI-ICANT 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 permission is granted as uested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this an y attached sh ef, in ude as general or special III provisions. <br />BignatuTitle � --- FaRe ' <br />»»»»»»»»»»>»»»>»»»>»»»FIELD INSPECTION (OFFICE USE ONLY)<<<«««««««:«««««««a««,< <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel t Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement [] Towards Pavement ❑ Flat <br />3. PIPES: None ❑ Existing -Type I 3,,e( <br />Other pipes in neighborhood: Yes NoApproaches Cross Drain Size__ <br />4. HEADWALL: Yes ❑ Noz <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No j <br />6. BARRIERS: along Right -of -Way, <br />7. DITCH: Yes A No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth _ <br />»»»»»»>»»>•r»»»»»» »»»»»>>>>>>>PERMITS REQUIREMENTS««««««««u,«««««««««<««< <br />1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture Industrial ❑ <br />Paved with —"Min Depth A.C. over J^_—"Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required Ft. and Diameter of Pipe J? P inch(es) <br />To be, connected to any adjacent driveway pipe Yes ❑ Non <br />Drainage Inlet Required Yes ❑ No [P�- <br />Total Length: __(with proposed) Total Number of Storm Drain Inlets: .— T <br />Notes: <br />3. HEADWALL: Yes ❑ Nok , <br />4. PAVED FRONTAGE: Paved with _ "Min Depth AC. over " Min Depth'W A.B. <br />Measuring _ Feet in length and Feetin width <br />»»»»»»>»»»»»»»»»»»»»»»»»»>»»FEES««<as<a«<,«««««««<araa<a««««««««« <br />Driveway Encroachment Pennit base fee $135.00 <br />L56, <br />field Ins ection <br />Drivewayw/orw/opipe_ $121.00 Paved Frontage �_$116.00+0.53Ift. <br />Driveway w/box Culvert_ _$161.O0 e Curb, Gutter, Sidewalk ,_$121.00+ 1.161ft. <br />XtlERCR AC NfENMWaslerFom Twopte$ENCROACUM W PERMIT OR9WAVdoc(OW08) <br />