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THE APPLICANT HEREBY CER T lFlES: <br /> That he/she has read ail the provisions of this applica ion,and that`the description included in this ap licatiot are correct to the irestctf <br /> his/her knowledge;and <br /> %. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That inefshe will assume full responsibility for a+l iiabiliy for persona;injury or damage to Property o t <br /> described above,or which may arise out or his/her failure to do the wok Qra✓ided herein:and wr ich may arts out of the work <br /> 4. That in the event any claim of such liability is made against the County of Sar,Joaquin or any department,official or e' <br /> thereof,he shall defend,indemn fy and hold them and each of them harmless for such claim:and Yee <br /> 5. That work shall be performed by the applicant and/or any representative of the app€icabon in the County Right-of-Way at the above <br /> indicated site v#Ji a valid San Joaquin County Encroachment Permit;and <br /> 5. That if permission is granted as requested,he agrees to do the work described in accordancewith all terms,condition and restriction <br /> of this and any attached sheet,inciuded as general or special III provisions. <br /> Signature of Appl€can Date <br /> »»»»>»»»»»»»»>»»»»»»»»> LD INSPECTION COMMEt+ITS««««««««««««««««cc««««c <br /> EXISTINGWITIONS <br /> DRIVEWAY: ^ Gravel Nene Dirt r .,rave Aggregate Base ❑ Paved(poor) 1E] Paved(good) 171 <br /> 2. SLOPING: Away from Pavement _ Towards Pavement 0 Flat <br /> 3. PIPES: None L7, Existing–1 ype <br /> W <br /> Other pipes in neighborhood: Yes _; No ii ' Approaches L; Cross Drain Size <br /> +. HEADWALL: Yes nib <br /> 5. ASPHALT CONCRETE DKE: Yes ❑ No <br /> S. BARRIERS: along Right-of-'Nay <br /> r. DITCH: Yes +i No '— f Yes I Style Ll 2 Pont Ef <br /> Other ? Widtt; Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS<e«««««««««««cz««««««<z« <br /> '. <br /> DRIVEWAY: SF-R "'Commercial - Agriculture J Industrial <br /> Paved with n Depth ! f,B,over <br /> "Klin Depth A.C.over t 3 <br /> Notes: ) { <br /> i. PiPES: Length of Pipe Required Ft.and Diameter of Pipe inch(es) <br /> To be connected to any ad,':acent driveway pipe Yes [] No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm grain inlets: <br /> Notes <br /> ? E I DWALL: Yes i_i No <br /> 4. PAVED FRONTAGE: Paved with 'Y' "`thin Depth A.G.over Min Depth 1ti°A.B; <br /> Measuring Feet in length and Feet in width <br /> »»»>»»»»»»»»»»»»»»»»»»»»»»»>FEES«««««««««<c««<c««««««««<t««««« <br /> Driveway Encroachment Permit base fea ;5444.44 <br /> Field in, ection <br /> y 1UnvevJay w!er w/o pipe 5107.00 F7 Paved Frontage <br /> Driveway w/box Culver 5975.40993.4 +0.5 /ft: <br /> Curb,Gutter,Wewalk5194.47 t 4.4a/ft. <br /> -aCEti"r,A!S'cRV�ES'CLERIC•n_�G35'J.W7,tih43TER.?SrE?fF.Or�^h+'c¢?=E�Atii CR,:V��'V;.AY.^u h. , ..} <br /> Page 2of2 <br />