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THE APPLICANT HEREBY CER-1TiF FS. <br /> 1. <br /> That he/she has read ail the provisions of this application,and that the description included in this application,are correct to the best of <br /> his/her knowledge:and <br /> 2. That heishe is the owner of the respective property.or is qualified to represent the ovmer:and <br /> 3. That he/she vili assume full responsibility for ail liability for persona;in ury or damage to proper L which mau arise out of the work <br /> described above,or which may arise out of hisiher 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 shall defend;indemnify and hold them and each of them harmless for such claim:and <br /> 5. That work shall be performed by the applicant and./or 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 /> >;. <br /> That: permission is granted as requested,he agrees to do the work described in accordance wb all terms,condition and restrictior <br /> of this and any attached sheet,included as general or special III provisions, <br /> S,t-' i§AaturdAcf Applicant Title / �C <br /> date <br /> »»»»»»»»»»»»»>»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None Di~ 71 Gravel 17 Aggregate Base L Paved(poor„ Paved;good) <br /> 2. SLOPING: Away frorn Pavement owards Pavement P/Flat <br /> 3. PIPES: N c n e L Existing-Type <br /> Other pipes in neighborhood: Yes LL No L! Approaches a Cross Drain Size- <br /> -4. HEADWALL: Yes 7 No `� f <br /> 5. ASPHALT CONCRETE DIKE: Yes Ji No ""r <br /> 6. BARRIERS: along Right-oLWay <br /> 7. DIT CH: Yes No 'L I if Yes: V Style 2 Point L= Other ❑ 14Mdth � ? Deptl' <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial L— Agriculture J Industrial <br /> Paved with "Min Depth A.C.over � "Min Depth YI"A.B.over <br /> Notes: �... � ',.a ,ax. •� ,'�rB ,} ". �`'•,�f.. �C ` r:... �,>, -:jr <br /> 2. PIPES: Length of Pipe Required . X Ft.and Diameter of Pipe inches) <br /> To be connected to any adjacent dr iveway pipe Yes ❑ No , <br /> Drainage Inlet Required Yes No [2r•'` <br /> "otal Length: ' ' (with proposed; Total Number of Storm Drain inlets: <br /> Notes. <br /> 3. HEADWALL. Yes J No 111' y <br /> 9 <br /> 4. PAVED FRONTAGE: Paved with "lin Depth A.C.over `Min Depth%"A.E. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit Vase fee $100.013 <br /> Field Ins mon <br /> I Driveway w/or who pipe 5107.00 Paved Frontage, SI 13.00+0.52/ft. <br /> Driveway w/box Culvert S175.00 � Curb,.Gutter,Sidewalk SA 10.00+1.05/ft. <br /> "h10EAiTk,ALS'cR,/R:)ESRC.E3,IG.,;:.;4'„v.VdB\Y&lot�cpSrEtr..R,,.,�nM*�d-PErt'�SIT J�'dAv'„,X, r,.4� pye2^`2 <br />