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THE APPUCANT- HEREBY CERT3 fS: <br /> 1 TIWt0 he haS Madall <br /> provisions of this appiication,and that the description include in this application are correct to the best of <br /> 2. T is the owner of the respective property,or is qualified to represent the owner;and <br /> 3 TW helshe wM,,;awwm fW,resporvbdityfor all liability for persona;injury or damage to property which may arise out of the work <br /> wed abom brifth may mise out of fisAw failure to do the work provided herein;and <br /> 4 That in the of such fiabllity is made against the County of San Joaquin or any department,official or employee <br /> *. mnify and hold#hem and each of them harmless for such claim;and <br /> 5 That work"t ed the app ant and/or any representative of the application in the County Right-of-Way at the above <br /> irWi0aW she a t a vaW wry Joaquin&ray Encroachment Permit;and <br /> g That ,perrnissw� as re ,he agrees to do the work described in accordance with all terms,condition and restriction <br /> as 1 or special ill provisions. <br /> of this ar�c3 y �,� � p� <br /> Sipan <br /> of Tide Date <br /> >>>>>> »»> »y�> »» >y»»>FIELD SECTION COMMENTS«««««««««««««««««««««< <br /> MOSTtNG CONDITIONS <br /> 1. DFIIVEWAY: None j(Dirt ❑ Gravel e Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2, SLOPING: Ajay from Pavement ❑ Towards Pavement [ Flat ❑ <br /> 3. PIPES: None ❑ E*g-TWe 131,0 I d rxi <br /> Ot,er p4mb ilk: Yes No Lj Approaches LJ Cross Drain Size i2 <br /> 4. HEADWALL: Yes ❑ NO <br /> 5. ASPHALT CONCH€ E Yes ❑ No <br /> 6. BARRIERS: abn Rkiht-a WaY <br /> 7, DITCH. Yes No C] if Yes. V SW 1. 2 Point ❑ Other [IWidth Depth <br /> »»»»»»»»»pERIM TS REQUIREMENTS««««««««««««««««««««« <br /> 1. DFUVEWAY: SFR Commercial ❑ Agriculture ❑ industrial [❑ <br /> Paved with 'Min Depth A.C.over "Min Depth 3/4"A.B.over <br /> Notes <br /> 2. PIPES: Length of Pipe Paquited Ft.and Diameter of Pipe inch(es) <br /> To be comWW to any adjacent driveway pipe Yes ❑ No ❑ <br /> DrajW Inst Required Yes ❑ No ❑ <br /> TOWLam; (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 3/a"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»>>>»»»»»»»»»»»»>>»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Pmt base fee--L—$90 00 <br /> F fionZ Paved Frontage $108.00+0.50/ft. <br /> rDd=mway <br /> way wf or W/o pipe $102,00 g <br /> wtbox Cutvert $167.00 HCurb,Gutter,Sidewalk $105.00+1.03/ft. <br /> Y;IOFMI6T0RtA POW OWMMY'ftP" <br />