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THE APPLICANT HEREBY CERTIFIES. <br /> 1. TWI Wshs has rent altthe,pr©vi of#i .�t�,S-d that the descripW included in this application are correct to the best of <br /> and2. Th*helsheiethe omw of#a:rhe property,or is quaffed to represent the owner;and <br /> 3. That heishe will assume full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> descrW above,or which may arise out of blather failure to do the work provided herein;and <br /> 4. That its the event any claim of such liability is made against the County of San Joaquin or any department,official or employee <br /> therW,he 09 dem,kK19 t 4 and hold them and each of them harmless far such claim:and <br /> 5, kswbg perhlrr l the is at.andlor any reps tWve of the application in the County Right-of-Way at the above <br /> a v c1 S Encroachment ;and <br /> 6. That N permission is granted as he agrees to do the work described in accordance with all terms.condition and restriction <br /> Of this and attar sheet,'ri as general or special III provisions. <br /> Date <br /> >>>>»» >>>»»>»>>>>>>>»>>»»»*ELO 111WION COWAEt4TS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br /> Omm C00011"S <br /> 1. DRiVEWAY4 Norte Dub O Gravel ❑ Aggregate Base Q Paved(poor) Q Paved(good) <br /> 4iu o's <br /> 2. SLOPING: Away from Pavement RTowards Pavement F Plat ❑ <br /> 3. PIPES: None <br /> Existing—Type <br /> Other pipes in neigI1ah&W Yes No $Ix aches U Cross Chafe U Size <br /> 4.. HEADWALL: Yes ❑ No <br /> 5 ASPHALT CONCRETE DIKE: Yes n No �'`✓� <br /> 6; BARRIERS: IWong lit-of-way <br /> 7. DITCH: Yes ❑ No f Yes: V Style ® 2 Point ❑ Other r, Width Depth <br /> >>»»»>»»»>»»>>»»»»»»»»»>>»»»1 i4ITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR 5?""'Commercial Q Agriculture ❑ Industrial ❑ <br /> j Pawed with / "Min Depth A.C.over �� J "Min Depth 1/4"Ap�.B.over <br /> Notes: &/,o <br /> 2.;PIPES: LLeog h,of Pipe Required Ft.and Diameter of Pipe inch(es) <br /> To�t�I to any nt driveway pipe nIel Yeses <br /> F1 No <br /> Toth Ling: (with proposed) Total Number of Storm Drain inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved wth "Main Depth A.C.over "Min Depth%"A.B. <br /> Measuring Feet in length and Feet in width <br /> sy»»>»»»»»»»>y>»»»»»»»»»»»>y»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee�__6100.00 <br /> Field Inspection <br /> Dittieway w/or w/o pipe $107.00 Paved Frontage $113.00+0.52Z111t. <br /> Driveway W/box Culvert $175.00 Curb,Gutter,Sidewaik $110.00+1.05'ft. <br /> U%CENSRAISERWE=LERH:A.1P'jSZV.WKAWTERPSseN„ROACHWNTPRtATORRVEW.AY.00C (10M) Pwe;02 <br />