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THE APPLIGAg'1iEREBY CERTIFIES: <br /> 1 { r theprovisions of this application,and that the description included in this application are correct to the best of <br /> 2. That haeisft Owner of the respective property,or is qualified to represent the owner;and <br /> 3. TWhes m assae full;responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> above,or which may arise out of his/her failure to do the work provided herein;and <br /> 4 Tit ayenty ciaimot such liability is made against the County of San Joaquin or any department,official or employee <br /> rtnify,and hold them and each of them harmless for such claim;and <br /> 5 - work"be peri rned by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> V*,Sen Joaquin County Encroachment Permit;and <br /> 6. Thatas requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> 16f.ftr0d aftfied sheet,included general or special III provisions. <br /> &C , <br /> of Applicant Title <br /> >>>,�,>>>>>>>.>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY* None ff"'Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> I AI <br /> Z SLOPING: Array from Pavement a Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: lie E*Ong—Type roaches Cross Drain Size <br /> > r PONrhood: Yes No App <br /> 4. BALL: Yes ❑ No <br /> 5. ASP'KT CONCRETE D#WYes ❑ No <br /> 6. BARRIERS: abry Right-of-way I <br /> 7. DITCH: Yes-❑ No Ej�If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »>>»>>>>>>»»»»>,>y»>>»>>»»y»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1 DRIVEWAY SFR all"Commemial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth 3/d"A.B.over <br /> NO.: {fel Wit <br /> 2 PIPES: Ler*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 Lam: (with proposed) Total Number of Storm Drain Inlets: <br /> Nom: <br /> 3. HEADWALL.: Yes ❑ No <br /> 4. PAYED FI WAGE: Paved with "Min Depth A.C.over "Min Depth 3/d"A.B. <br /> f 4 Measuring __ Feet in length and Feet in width <br /> »»»»>>>>>„»»»»»»»>y»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $90.00 <br /> Field"lrivewaywMx Culvert $102.00$167.00 8 Paved Frontage $108.00+0.50/ft. <br /> y w�or w!o pie Curb,Gutter,Sidewalk $105.00+1.03/ft. <br /> Y; 6.d TF�WtAM pEAWT pgIYEWpY.tl"e(68R1�1 <br />