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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all:ther '! <br /> provssic rs at this on,and that the de s€xip4i n included in this app Torn are MW tsa,9*bat of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified 10 represent the owrner;and <br /> 3. That he/she will assume full respormbility for all 1 ' for persona;injury or dam to property which may arise out of the work described above,or which may arise out of h3slher to do the work prdA Win;and <br /> 4. Thatin the event any claim of such4kability is made against the County of San Juin or any department,Wrial or esnooyeo; <br /> therieof,he shall defend,indemnify and hold them and eadn of theist harms for such claim;and <br /> 5. That work shag be performed by the applicant andlor any representative of the application in the County Right-of-Way at to above <br /> inditMed site with a valid San Joaquin Gourity Encroachment Permit;and <br /> 6. That if permission'a r�ed s ested,he gees to do the work described in accordance with all terms,condition and res ion <br /> of this and i or s 111 provisions. <br /> -- <br /> »»»>»»�» »»»»»»»»»>>>>»PIEiD Mffaft C �'Sic««<««<<«a«c«««<�c««««c�c«<«« <br /> EAST11YC3 C:C f1'ONS <br /> 1. DRIVEWAY: None F-1 Dirt Gravel Aggregate Base Q Paved(pocrr) n Paved(good) d <br /> 2. SLOPING: Awray intim Pavement 7. Towards Pavement r Flat <br /> 3 PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes No Loof des Cross rain Size <br /> 4. HEADWALL: Yes E No w <br /> 5. ASPHALT CONCRETE DIKE: Yes nI No <br /> 6. BARRIERS: along Right-of*ay I'le <br /> 7. DITCH: Yes 0 No If Yes: V Style Q 2 Point f-1 Other Q Width Depth <br /> »»»>>»»»»»>>»»»»»»»»»»>a»»>>PER it 'S REQU r EM ENT$«<,,c<««««««««««<«««<<<<<<<<< <br /> 1. DRIVEWAY: SFR Commercial Q Agriculture (] Industrial Q <br /> Paved with "Min Depth A.C.over "Min Depth"l4"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe inc ages) <br /> To be connected to any adjacent driveway pipe Yes 0 No <br /> Drainage Inlet Required / Yes Q No <br /> Total Length: {with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes El No <br /> 4. PAVED FRONTAGE: Paved with * 'Min Depth A.C.over °Min Depth af4"A:B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»>'»»»>»»»»»>»>}»»»>»»»>»»>FEES« t«<a«««<tc««c<t««««««<<«<<e««ctc«« <br /> Driveway Encroachment Permit base fee $100.00 <br /> Fie <br /> driveway w/or w/o pipe $107.04 � Paved Frontage $113,00+0.52fit <br /> Driveway wribox Cuivet $175.00 Curb,Geller,Side's $110.00+1.0S& <br /> rANCENTRALSERVICE=LERICALwuS-$V.WKUS?ER.MEr;ci OACHw t4TaEW txzr eWA U c t, PSW2of2 <br />