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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That hei'she has.read all the provisions of this application,and that the description included in this application,are correct to the best of <br /> hls/hei knower and <br /> 2. That heishe is the owner of the respective property;or is qualified to represent the caner:and <br /> 3. That he/she will assume full responsibility for all iiability for persona;injury or damage to proper'ry w cion may a^se 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 shad defend,indemnify and hold them and each of them harmless for such claim:and <br /> 5. That work shag-be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> i�siteAft a valid San Joaquin County Encroachment Permit;and <br /> 6. That if perrrti as res ,he agrees to do the work described in accordance with ail terms,condition and restriction <br /> Of this any s as general or special 111 provisions. <br /> Sovftre of Applicant Title Date <br /> »»»>x»»»»»»»»»»»»»>»»»»FlELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: Nave [3 Dirt Gravel [Aggregate Base raved(poor Paved;good; <br /> 2. SLOPING: Awray from Pavement Towards Pavement Plat 71 <br /> 3. PIPES: None Existing—Type <br /> Cather pipes in neighborhood: Yes No Approaches Coss Crain, !? Size <br /> 4. HEADWALL: Yes El No . <br /> 5. ASPHALT CONCRETE DIKE: Yes F NoV <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No If Yes: V We [] 2 Point Q Other Width Dept, <br /> »»»»»»»»»»>y»>>»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1 DRIVEWAY: SFR Commercial Q Agriculture 7 industrial � <br /> Paved with ., "Min Depth A.C.over " 'Win Depth 3/W A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter ci Pipe inches) <br /> To be connected to any adjacent driveway pipe Yes 7 No <br /> Drainage Inlet Required Yes ® No <br /> Total Length: (with proposed) Total Number of Stcr, ,Drain iniets: <br /> Notes: <br /> 3.. HEADWALL: Yes [I No 211, <br /> 4. PAVED FRONTAGE: Paved with 1'1114_ "Miro Depth A.C.over „Min Depth 3/.".4.B. <br /> Measuring Feet in length and f=eet in width <br /> >>>y»»>y»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $l 00.00 <br /> F' <br /> elo Inspection <br /> W/or W/o pipe <br /> Driveway W/bar Culvert_$175.00 <br /> �175.Et4 107.00 Paved outage 3 ,"s.?C+ .5�'ft. <br /> --? Curb;Gutter.Sidewalk S ,0.00� ;.?51ft. <br /> w �l <br /> NCk:ENrAk'SERMESVCLSCALPUS$Y.W9WSTER.P$1EN^ROAr—HKENFPER QRIVEWAY.r,OC �iOrQ&; ?age 2-?2 <br />