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THE APPLICANT HEREBY CERTIFIES: <br /> That he/she has read ail the provisions of this appii�tio�;and that the deso"w4icluded in this app car �.fie <br /> his/her knowledge;and <br /> 2. T'nat he/she is the owner of the respective property,or is qualified to represent the ower;and <br /> 3. That he/she will assume full responsibility€or all liability <br /> €or persona:injury or damage to property which may arise Wof the y <br /> described above,or which may arise out of his/her failure to do the wt*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,OMCW or erroo <br /> thereof,he shall defend,indemnify and hold them and each of there 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 fight-pf-Way <br /> indicated site with a valid San Joaquin County Er croachrr d Permit;and <br /> 6. That if permission is granted as;requested,he agrees to do the work described in accordance with all terms,COrldition acrd rt: Ctiran <br /> of this and arty t,included as or spial 111 provisions: <br /> 11�A. 2z I <br /> Signature of ApI <br /> »»»»»»»»»»»»»»»»»»»»»>FELEa NVECTION COMMENTS<K««««<<«<<«<««« <<<+c <br /> EVI STING CONDI t' S' <br /> '. DRIVEWAY: None Dirt 0 Gravel ❑ Aggregate Base [] laved(poor) L7 Pavers(good) � <br /> 2. SLOPING: Away from Pavement 7, Towards Pavement Flat (� <br /> 3. PIPES: Norse Existing—Type <br /> Other pipes in neighborhood: Yes No Aploroaches Cross Drain <br /> 4. HEADWALL: Yes Q Na " <br /> 5. ASPHALT CONCRETE DIKE: Yes L7 No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes L j No g4Yes:Yes: V Style 2 Faint fl Other Q Width Depth <br /> »»»»»»>>»»»»»»»»»»>y»»»»»»PERMITS RIEQUREMENTS«««««««««<«<,<c<<i<<e« �«<4k< <br /> 1. DRIVEWAY: SFR [Commercial F� Agriculture ❑ Industrial [( <br /> Paved-with "Min Depth A.C.over "Win Depth W A.B.,ov/er <br /> Notes: > il <br /> eve� 4 <br /> A > '+a• <br /> 2. PIPES: Length of Pipe Required Et.and Diameter of Pipe <br /> To be connected to any adjacent driveway pipe Yes QNo <br /> Drainage Inlet Required Yes Q No <br /> Total Length: ry" " (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWIALL: Yes No ( '' <br /> 4. PAVED FRONTAGE: Paved with "? "Min Depth A.C.over Min lith J4"A.B, <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»>»»»»»»»»»»»»»>FEES«`«a«<«««<<««<<«««««c«rc««,c<i««<<<<<< <br /> Driveway Encroachment Permit base fee 100.0 H <br /> Feld In 'an <br /> Driveway w/or w/o pipe 107`0 Paved Fronta $1#3.04+0.51ffL <br /> Dnvevray wlbax Culver Curb,Gutteridewatk $190.00 f 1.0611t. <br /> V'LEN"tiALSERME=LERiCALipub-AV'M(VX%Ut3?ER,PS\ENCRQACH?&NTr"ERA�DRIVEE'WAY.DOC {1010"2! Page�of2 <br />