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THE APPLICANT HEREBY CERTIFIES: <br /> 1• That helshe has read all the provisions of this application,and that the description included in this application are correct to the es <br /> hislter knowledge;and best of � <br /> 2• That helshe is the owner of the respective property,or is qualified to represent the owner;and <br /> 3• Thal he/she will assume full responsibit4 for all liability for persona;injury or damage to property which may arise out of <br /> described above,'or which may arise out of his/her failure to do the work provided herein;and the work <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 andlor any representative of the application in the County Right•o <br /> indicated site with a valid San Joaquin County Encroachment Permit;and f Way at the above <br /> 6. That if permission is'grented as requested,he agrees to do the work described in accordance%with all terms,condition and restriction <br /> of(his and any attached sheet,included as general or special III provisions. <br /> 1011113 <br /> Signature TApplicantTIlle ate <br /> »»»»»»»»>»»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««« <br /> EXISTING CONDITIONS. «««< <br /> 1. DRIVEWAY: None 52-*'Did ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) <br /> 2, SLOPING: Away from pavement 01"Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None [eExisting--Type <br /> N�� <br /> Other pipes in neighborhood: Yes LJ No <br /> Approaches Cross Drain <br /> 4. HEADWALL: Yes ❑ No [� <br /> 5. ASPHALT.CONCRETE DIKE: Yes ❑ No ITI <br /> 6. BARRIERS: along Right-of-Way l 0 li-e- <br /> 7, <br /> 7. DITCH: Yes ❑ No if Yes: V Sty le <br /> ❑ 2 Point ❑ Other ❑ Width Qepti, <br /> >>>>>>>>>>>»>>>>>>:>>»>>>>>>>>>>>>>>>>>>>>>>>>>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR I� Commerclal ❑ Agriculture ❑ Industrial ❑ <br /> Paved with Z Min Depth A.C.over_ , „ <br /> Min Depth/. A.B.over <br /> Notes: 0 7 �oc= w h'-1 S' <br /> r` <br /> 2. PIPES: �/ <br /> Length of Pipe Required /Y 114 Ft.and Diameter of Pipe A/ //J <br /> Tobeconnected to any adjacent driveway pipe Yes ❑ No [� inch(es) <br /> Drainage Inlet Required Yes [] No [� <br /> Total Lenglh: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL; Yes ❑ No <br /> i <br /> 4, PAVED FRONTAGE: Paved with °Mln Depth A.C.overMtDepth/<, , <br /> Measuring feet In length and----.Feet In width <br /> »»»»»»»?7»»»»»»>»»D>»»»»>»»»>»>FEES««««««««««««««««««««««<t«««« <br /> i <br /> Driveway Encroachment Permit base fee $135.00 <br /> s i <br /> Figmyw/boxCuvert <br /> /or w/o pipe X121.00 l $18100 Paved Frontage $116.00+0,53/11. <br /> I'ICeffMOCR'4CESIGLEItIGALTU&SV.Yl1flUSTERpSIEW OACW.lEnTPEALVfIMMA)WOC(W13) ® Curb,Gutter,8idewalk»$121.00+1.1610. <br /> Papa 20f 2 <br />