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THE APPLICANT HEREBY CERTIFIES: <br /> �. Thai helshe has read all the provisions of this application,and that the description Included in this application are correct to the.best of <br /> his/her 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 will assume full responsibility for all liability for persona;injury or damage to property which may arise out of ilia 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 shall defend,Indemnify and hold them and each of them 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 Right-of-Way 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 accordance with all terms,condition and restriction <br /> ofthis and any attached <br /> sheet,included as general or special III provisions. <br /> 7!� �L G17Ns 7f HGT Fln� /Q �� <br /> V Signature of Applicant Title ate <br /> »»»»»»»»»>»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< . <br /> EXISTING CONDITIONS <br /> i. DRIVEWAY. None (v" Dirt ❑ Gravel ❑ Aggregate Base <br /> Q Paved(poor) Q Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Fiat [� <br /> 3. PIPES: None R Existing—Typo 1,11 <br /> Otherpipes in neighborhood: Yes No roaches <br /> i4pP Cross Drain Size_ <br /> 4. HEADWALL: Yes ❑ No Q� . <br /> 5. ASPHALT CONCRETE DIKE., Yes ❑ No//,[� <br /> 6. BARRIERS: along Right-of-Way 110ne- <br /> 7, DITCH. Yes 93--'No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width <br /> 41 Depth <br /> »»»»»>'»»»»»»»»»»>»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> i. DRIVEWAY: SFR ❑ Commercial b3 Agriculture ❑ Industrial ❑ <br /> Paved with 2 "Min Depth A.C.over"Min Depth V"A.B.over or �o>rc�e�e C'o TE✓h7,;T <br /> Notes: fo SJ.Co __ <br /> 2. PIPES: Length of Pipe Required <br /> Ft and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes 63"No <br /> Drainage Inlet Required Yes El No � - <br /> Total Length: _ (with proposed) Total Number of Storm Drain inlets: � /a <br /> Notes: Lin o erh� Co�aYiea SJ. Cover �1 /Jt i,/a. 2a/7 <br /> Or P S'dr���T�rf �/%✓P,Gva �hl Q�� / 1 <br /> 3. HEADWALL: Yes ❑ No [ or l0el <br /> 4. PAVED FRONTAGE: Paved with � <br /> 'Min Depth A.C.over _^ ^Min Depth%4 A.B. <br /> Measuring f=eet in length and Feet In width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee <br /> ^� 60 34� <br /> Fia►d fns action <br /> Driveway w/or wlo ppipe $ 10.aooey) <br /> Driveway w/box Cutvert Paved Frontagge $t t 6,fl0 t 0.5?�ft. <br /> t + � Curb,Gutter,Sldewa k $l 14. 0+1.08lft <br /> Y:VORJAS 8 TOl�L1TE .iCfi4EMTPEFSYT IXLVEIYAY.doc( CRj . <br />