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THE APPLICANT HEREBY CERTIFIES. a . <br /> 1. That hefshe has read all the provisions of this application,and that the description included in this application are correct to the hest of <br /> hisfler knowledge;and <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 Y&I assume full responsibility for all liability for persona;injury or damage to property which may arise out of the worir <br /> described above,orwhieh may arlse out of his/her failure to do the wok 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 shal4 defend,indemnify and hold them and each of them harmless for suet:claim;and <br /> 5. That work shall be performed by the applicant andlor any representative of the appiication in the County Right-of-Nay 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 accordanceofiti°°all terms,condition and restriction <br /> of this and any attar sheet,included as or special III provisions. <br /> tat( .t„✓^ '•_ <br /> Suture of A Title Date <br /> d;. <br /> »»»»»»»»»>s^»»»»»»»»»»»>FIELD INSPECTION Ct?M#AENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None,[, Dirt Gravel Q Aggregate Base F-1 Paved(poor; " Paved(good) j <br /> 2. SLOPING: Away from Pavement 71 Towards Pavement Flat ''�� <br /> 3. PIPES: Norse OExisting—Type <br /> Other pipes in neighborhood: Yes Lj No ; Approaches ; Cross Drain, i_ Size. <br /> 4. HEADWALL: Yes 17 No ' <br /> 5. ASPHALT CONCRETE DIKE: Yes F, leo <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes 0 NO ' f Yes: V Style 0 2 Point ❑ Other El `1.1i th Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««<cE«««««««< <br /> 1. DRIVEWAY: SFRCommercial 7 Agriculture 17 industrial <br /> Paved with F tt "Min Depth A.C.over 111in Depth 1/0 A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required "-.`x Ft.and Diameter of Pipe <br /> To be connectedto any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: ;with proposed' Total Number of Storm Drain iniets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No " <br /> 4. PAVED FRONTAGE: Paved with "Mir,Dept's?A.C.over ;a"in Depth%'A.B. <br /> Measuring Feet in length and Feet in width <br /> »y»»»»»»»»»»»>y»»»»»»»>»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $100.00 <br /> F I n <br /> Driveway w/or w/o pipe $107.00 PavedFron€age $1 52?«. <br /> Driveway wfbox Culvert <br /> $'+75.00 !1 Cutter.Sidewalk S 1;0."C !ft. <br /> M:'CENTPALSERViCE$rLE+RICAL'IPUMV.,l1:iPf!4Si cR.PV3 ENCROAC'r?,I&NT PERVT MVE'.VAY 00 Gr06, °mo 2^`2 <br />