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THE APPLICANT HEREBY CERT FIES: <br /> 1. That he/she has read all the provisions of this application,and that the description included in'his application are correct to the.best of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the'respective property,oris qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for persona;inury or damage to properjl 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 of any department,official or employee <br /> thereof,he shall defend,indemnify and hold them and each of thein ha,miess for such 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 /> S. That if permission is granted as requested,he agrees to do the work described in accordance with ail terms,condition and restriction <br /> of this and any attached sheet,included as general or special Ill provisions. <br /> > l <br /> Signature of Applicant Title Date <br /> »»»»>»»»»»»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««<. <br /> EXISTING CONDITIONS <br /> ?. DRIVEWAY: None ❑ Dirt ❑ Gravel k Aggregate Base ❑ Paved(poor) [] Paved(good) v <br /> 17 <br /> 2. SLOPING: Away from Pavement Towards Pavement Flat <br /> 3. PiPES: None Existing—Type 157"' JJ©� dvJ.u- <br /> Other in net hborhood� JAG i� � <br /> .g ❑ No Approa..hes 1 Cross Drain I Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 5. BARRIERS: R' ;,t-of-VVay <br /> 7. DITCK Yes No#If Yes: V Style 172.Point Li Other n Width Depth <br /> »»»»»»> »»>»»»»»»»»»»»»»PERMITS REQUIRE TS««««««««««««««««««««« <br /> �tC,g✓RTl�,n,C <br /> DRIVEWAY: SFR [] Commercial ❑ Agricultureik Industrial <br /> Paved with "Min Depth A.C.over "?�4in Depth 1/4"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required _ Ft.and Diameter of Pipe inch(es) <br /> T c be connected to any adjacent driveway pipe Yes ❑ No 17 <br /> Drainage inlet Rea.fired 'Yes Q No ❑ <br /> Total Length: (vrth propose ) Total Number of Storm;rain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes [-] No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over Min Depth'/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> ,Xiveway Encroachment Permit base fee g 12S• 66 <br /> R ins ection <br /> Driveway w/or w o pipe $ ll o• a t—i Paved <br /> Fr..n>:ag2 $113.00+C�.521ft. <br /> i Driveway w/box Culvert S?75.OQ tj Curti;Gutter,Sidewalk—5 110.00 1.05,1W. <br /> Pl:'C_N7 !SER'JICEStCL`cR,C:Ji;6-S'J.VJ'!.',Ph557Eri.PS1Fi;;P,pq;;;;,n �?p MJT QRNEWAY.CGC ;!GG&; Page'e 02 <br />