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' { HEREBY <br /> E r <br /> `!r APPLICANT ra�Rc$Y CER iIFiES: <br /> 1. That heishe has, <br /> all the provisions of this application,and that the description included in this applicator,are correctto the best of <br /> his/her knowledge:and <br /> 2• That helshe is the owner of the respective properly,or is qualified to represent the owner.and <br /> 3. That h"eishe will assume fuli responsibility for Q i liability for persona:injury or damage to property which may a;se out of the work <br /> described above,or which may arise out of his/her failure to do the wo,ic provided herein;and <br /> 4. That in'he event any claim of such liability is made against the County of Sar,Joaquin or any department,official oren ee <br /> thereof,he shall defend:indemn y and hold them and each of them harmless for such claim:and <br /> 5. That work shall be performed by the applicant andfor any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in actor dance with all terms,condition and res;ric6on <br /> of this and any "cached sheet,included as general or special III provisions. <br /> x 0123 by <br /> Signature cf.Aapplicant r ie ate <br /> »»»>»»»»»»»»»»>»»»»»»»>FIE'LD INSPECTION COMMENTS«««««««««««<t«'e««««<«<et<< <br /> EXISTING CONDITIONS <br /> '. DRIVEWAY: None ❑ Dirt LZ Gravel [❑ Aggregate Base [] Paved(poor) IL--! Paved(good; 1 <br /> 2. SLOPING: Away from Pavement i,�` Towards Pavement Flat 17 <br /> 3. PIPES: None Existing—Type Al ✓'' <br /> Other pipes in neighborhood: Yes I_, No }1, Approaches i_, Cross Drain J Size <br /> 4. HEADWALL: Yes ❑ No l -, <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [g,"' <br /> a <br /> 6. BARRIERS: along Right-of'-Way <br /> DITCH: Yes ❑ No e if~Yes: V Style � 2 Point El Other � Width Depth 4 <br /> »»»»»»»»»»>>»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««t<<<««« <br /> 1. DRIVEWAY: SFR 2'""Commercial ❑ Agriculture ❑ Industrial F__1 <br /> Paved with "Min Depth A.C.over "Min Depth W A.B.over <br /> Notes: - M <br /> 2. PIPES: Length of ripe Required Ft.and Diameterof Pipe <br /> inch(es) <br /> To be connected to any adiacent driveway pipe Yes No <br /> Drainage inlet Required Yes n No -,. <br /> Total Length: ,With proposed; Total Number of Storm Drain Inlets: <br /> Notes: <br /> ... i'lEADWALL: �V <br /> eS a No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "fain Depth V A.B. <br /> Measuring Feet in length and Feet in Width <br /> »»»»»»»>'»»»»»»»»»»»»»»»»»»»FEES«««<<««««««««««««««««««««««<< <br /> Dnve%vay Encroachment Perm^base fec 5100.00 <br /> Field inspection <br /> T , Driveway vv/or w1J pipe 07 M, <br /> ! F. a1�r.i C axed Frontage ?13.00+0.52fft. <br /> %'i Driveway wibrx Culvert 0175.00 1 Curb,Gutter, Sidewalk 51 10:10+1.05ift <br /> -0.10EyikA�S'ccRVICES'C;.EP„G4_L�UPrS'J:JJ'f.4ifo-',:?ER7S't�uCRpgCH?a'y;di FERd/.rT CP.;'J�W.1Y.�(iC.. ,}C:L <br /> ^) Page 2 ci 2 <br />