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THE APPLICANT HEREBY CERTIFIES: , <br /> 1 That he/she has read all the provisions of this app *tion,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 respecti+Ee 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 /> dem 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 shad deed,indemnify and hold them and each of them harms for such claim,and <br /> 5. That ski be perforrried the applicant,and/or any rVreseritafire of the application in the County Right-o#Way at the above <br /> i site a vakr!San tw*Encroactiff 0 permit;and <br /> 6. That if Pet�n is meted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> Of tet' and arty attach III provisions. <br /> (,- \ <br /> attire Applicantfate <br /> »»»»»>»>»»»»»»»»»>>»»»»>FEW It "ECTIM NTS««<<««««««««««««�r««<c«tt« <br /> E�tSTII��fNS <br /> 1 DRIVEWAY: None ❑ Dirt [ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) <br /> 2. SUING: Away from P vement Towards Pavement ❑ Flat Q <br /> 3. PIPES: None Existi Type <br /> Other pipes in neigh : Yes No Approaches Cross Drain Size <br /> 4, HEADWALL: Yes F-1No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-way V0,111 e. <br /> 7. DITCH: Yes ❑ No If Yes: V Style ❑ 2 Point ❑ Other ❑ Widfh Depth <br /> »»>>»>�,»»»»>y»»»»»>>»»»y: >>>>>PERMITS REOWREME TS««�t«««4««««««««««««««« <br /> 1 DRIVEWAY: SFR ❑ Commercial Agriculture ❑ Industrial <br /> Paved with ?I "Min Depth A.C.over. `y' F r "Min Depth%"A.B.over <br /> Notes: 4U c0,P#brae,qn h✓r S., .t"�r , ' 4 ° X-/ <br /> j�.�"�Y t.�; �`,�` ``"I� s/'/>'+;;f�sr"+,�'.7 j"'•�as',i�€s ...��a� ,* e�,' "':.�'�"". '�/ G��f� f �r`+�'`j e ,f t s; �'.,�:g�!+3i'�.V "'`'�r r'/�-"° <br /> t <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter oj Pipe <br /> inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No riK <br /> Total Length: (with proposed) Total Number of Storni Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Lli'/4"A.B. <br /> Measuring Feet in tenth and Feet in width <br /> »»»»»»>»»»»»>y»»»»»>»»»»»»»»IrEES««««<t««««««««<«««««««««««««< <br /> Driveway Encroachment Permit base fee $100.00 <br /> Field <br /> Drive vy w/or w/o pipe $107.00 ❑ Paved Frontage $113.00+0.52/ft <br /> Driveway w/box Culvert 5175.00 ❑ Curb,Gutter,Sidewalk $110.00+1.05/ft <br /> 1R'CkNiRkSE.R=E$ttERICALWUBSV.WKUUT£R.Pge4CROAC"AeN',PEPMTDit MAI.€OC (i=q) PsV202 <br />