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THE APPLICAW HEREBY CERTIFIES: <br /> 1 That helshe has read all the provisions of this app anion,and ttrat the demon trr riled In this applicatiors are correct to the best of <br /> hMw kn `. ;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 M responsitalky for all liarh y for persona;injury or damage to property which may arise out of the work <br /> described above,or which may arse out of hisiber failure to do the wok prod herein;and <br /> 4. That in the,event any cWm of such liability is �madethe County of San Joh or any department,official or employee <br /> th f,he"did,iricf6m ty and hold therm each of them harmless for stidl tin;and <br /> 5. That work shd be performed by the ap nt and/or any representaltve of the application in the County Right-of-'stay at the above <br /> indicated silla,v t a valid San Joaquin County Encroachment Perm and <br /> ti. gran requested,he gees to do the work described in acoordano with all terms.condition and restricticn <br /> and y sh included as general or special III provisions <br /> Signer of Appitant <br /> >'»»»»»»s»»»»»»»»»»>>>»> JEtD IWE TIIfJAt COWENt$<<+t«««««««««««««««««««« <br /> EASTffVt3;COND#SIS r�a t $x, n `evx,• � <br /> 1. DRIVEWAY: None E,'Dirt'17 Gravel Fj AggregateBase E) Pawed( ) Paved{good} Fj <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat <br /> 3. PiPE5. None Q Existingi 1 fa d lir C _J"a�,d J/ 4 arj 3 ' ,` .o,, as d <br /> Other pilm in rieighborhoo& Yes No Lj PW09c 5�ft biw <br /> 4. HEADWALL: Yes n No [ <br /> 5, ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along bight-cif Way � ? <br /> 7 DITCH: Yes ❑ No if Yes: V Styie [] 2 Point M Other a Width _ Depth /V ,,j F <br /> »»>»»»»»»»»»>>>a»»>»»»»»»>>>>PMITS F JOWJM ii'I`S<<:«<««««««««««««««««e«<< <br /> 1. DRIVEWAY: SFR Commercial Agriculture [] Industrial <br /> Paved with 12 "Min Depth A.C.over "Min Depth 3W A.B.over <br /> Notes: �ha 2 �• — ---- <br /> 2. PIPES: Length of pipe Required L 2t�t.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 St/o�rm,tDrain iniets: <br /> Notes: d• t�..ff'1 ;,'.ta'a=` '^`',. '4x'.t '•"X«sr,� =f9...:y>. ,�',.! 'G'rC�Lnv';jpl� f.w�6,6',;a r°f= ✓".` ;t <br /> r'd sJ? fl �r d'rF'rrf m < er: A% fsr , <br /> +w.�i~a?G1^1� �+''� F°t��Jw`�''' a.'16''` t,��'j �a"`'�,�`��"tr ,` ad ..,;,�.. X�`r: i!`d'�,'"✓ '�;1 <br /> 3. HEADWALL: Yes No ` �''rG <br /> 4. PAVED FRONTAGE: Paved with <br /> "Min Depth A.C.over "Min Depth 3/4'A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»>»»»»»»s>»»>>>»»»»»»»»»»FEES<K«««<c«««««<<<<««««««««««««««« <br /> Driveway Encroachment Permit base fee $100.00 <br /> Field IrlWWE <br /> Drfveway,A#or w/o pipe $107.00 Paved Front�e t. <br /> $113.00+0.52, <br /> Drive**w1box CuK tt $175.00 Curb,Gutter,-8 $140.00+1.051ft. <br /> MNCENn;!ALWRVICESL",MCALIPUB-SVWKWASTER.PSVENMOACNWNTPERKVT DRIVEWAY DOC (IMP) Page7.of2 <br />