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THE APPLICANT HERESY CERTIRES: <br /> 1. That he/she has read all the provisions of this application;and that the�included in this application are.=Ted to the best of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified rep nt the sem;and <br /> 3. That he/she will assume full responsibility for all liability for persona irijuryor4arnap'to property which may arise out of the work <br /> described above,or which may arise out of his/her failure to do the ark pvAded"hers;and <br /> 4. That in the event any claim of such liability Is made against the County of Sep Joe=or any epartmorik oto oremployee <br /> thereof,he shall defend,indemnify and hotd fhem and each of them harmless for cin,and <br /> 5. That work shall be performed by the ap )cant and/or any r esentative of the app�r in the Cory Right-ol y at#he alar <br /> indicated site with a valid San Joaquin rty Encroachment Perm&;and <br /> 6. That if permission is granted as requested;he agrees to do the work,descrW in accordance with all term. m <br /> s, on and resin <br /> of this and any attached sheet,included as general or sped ill Prov�na <br /> Signature of int'Title <br /> »»»»»»»»»»»»»»»»>»»»»»FEW SECTION <br /> E�fSTIt�G��l" <br /> 1. DRIVEWAY None [Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) <br /> 2. SLOPING.41i Away from Pavement ❑ Towards Pavement ❑ Fly <br /> 3. PIPES: None R""EExisting—Type <br /> Other pipes in neighborhood: Yes U No UApproad t5rbw Size <br /> 4. HEADWALL: Yes ❑ No [ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ <br /> 6. BARRIERS: along Right-of-Way aid <br /> 7. DITCH: Yes ❑ No 5?ff Yes: V We ❑ 2 Point ❑ Other,❑ VVI Dpi <br /> >>>»»»»»»»»»»»»»»»»»>»»»PEftN RAJ #T <i*-<<<<<<<<<<<<<<"<<<<<<<<<<<,<<<<<<,<<<<< <br /> 1. DRIVEWAY: SFR a,5'Cornmerdal ❑ Agriculture Q', Industrial <br /> Pavedwith "Min Depth A.C.over "Min Depth,%V A.B.over <br /> Nates: <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 r-`` "Min Depth A.C.over "Min Depth'I<"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»>»»»»»»»»>»»»»>»»»»»»»>1+EEg«<c«««�«««««<t«««<<««««««t««««« <br /> Driveway Encroachment Permit base fee $100.00 <br /> Field InsDection <br /> Driveway w/or w10 pipe $107.00 X Z Paved Frontage $113.00+0.52/ft. <br /> Driveway w/box Culvert $175.00 B Curb,&,SltYewalk $110.00+1.05/ft. <br /> V-ZENTRALSERVICESICLERICALPJ"V.WKVAkSTER.PSEWROACHMNTPERWT.DRfVEWAY.DOC (Mg) Pap2oQ <br />