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THE APPLICANT HEREBY CERTIFIES. <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> his/her knowledge:andel <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner:and <br /> 3. That he/she will assume full responsibility for aii flability for persona,injury or damage to grope!ty which may arise out of the work <br /> described 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 shall defend,indemnify and hold them and each of them harmiess for suc 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 /> 6. That if permission is granted as requested.he agrees to do the work described in ax- ordance with ail terms,condition and restriction <br /> of this and any attached sheet,in-luded as cial Ili provisions. <br /> Signature of Apocant Titie <br /> »»»»>y»»»»»»»»»»»»»»>FIELD INSPECTION COiAMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None (1 Girt Gravel ice, Aggregate Base r7 Paved(poor) Paved good) <br /> 2. SUING: Away from Pavement1;; Towards Pavement Flat <br /> 3. PIPES: NonejExistina-type <br /> Other pipes in neighborhoad: Yes too t Approaches , ^,ross Grain Size _ <br /> 4, HEADWALL: Yes E] No <br /> 5. ASPHALT CONCRETE DIKE: Yes r No,l <br /> 6. BARRIERS: along Right-of-Way <br /> i.. DITCH: Yes 7 No t�.� Ii Yes: V Style 7 2 Point Other U i%idth tenth <br /> »»»»»»»»»»»»»»»»>»»»»»»»>PEIRMITS 1REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial Li Agriculture _,i industrial <br /> Paved with "fair?Depth A.C.over >' " tin Depth 4"A.B.over <br /> Notes: �'Jt J 41 <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter o4 Pice inches) <br /> To be connected to any adjacent driveway pipe Yes ❑ No Efi� <br /> Drainage Inlet Required Yes No 2:t" <br /> Total Length: with proposed) Total Number of Storm Drain iniets: <br /> Notes: <br /> 3. HEADWALL: Yes 0 No .. <br /> yy ° <br /> 4. PAVED FRONTAGE: raved with " lin Depth A.C.over Min Depth%"A.B <br /> Measuring Feet it length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $100.00 <br /> Field Inspection <br /> ! Driveway wi or wio pipe $107.00 `i aved Frontage SI 13.0-0+0.521ft. <br /> Driveway wibox Culvert_ 5175.00 i ,urb. Gutter.Sidewalk S1;O.to 1.05/ft. <br /> y:`CEti?P.A!SERfCES1C:E!?fCkt.1PU3S'l:JVK1kAS?cR 7S1EtiC�'O�;:h:FN?%En'hS7T D?i'JE.1NriY.!?C:'. ;SC;L:F:; �;tge2:t2 <br />