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THE APPLICANT HEREBY CERTIFIES: <br />1. That he/she 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 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 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 performe 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 S , Joaquin County Encroachment Permit; and <br />6. That if permission ia-gran Jd as requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this and any attached.`46 <br />eet,-included as general or special III provisions. <br />Sinnande of Anolicant Title Jim <br />EXISTING CONDITIONS 1 <br />1, DRIVEWAY: None .' Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) LI Paved (good) ❑ <br />2. SLOPING: Away from Pavement [I TowardsPavement El Flat 0 <br />u <br />3. PIPES: None Existing—Type <br />Other pipes in neighborhood7–Y–e—so No Ll Approaches U Cross Drain Ll Size <br />4. HEADWALL: Yes ❑ No [.7l <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No [J <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No [A If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»>»»/»»»>»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR ❑ Commercial Q Agriculture ❑ Industrial ❑ <br />Paved with Y "Min Depth A.C. over (+ "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: (with proposed) <br />Notes: <br />3. HEADWALL: Yes ❑ No <br />Ft. an�d/Diameter of Pipe � <br />No 5r <br />No <br />Total Number of Storm Drain Inlets: <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth'/<" A.B. <br />Measuring Feet in length and Feet in width <br />»»>»»»»>»»»»»»»»»»»>»»»»»»»»> F E E S ««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00 <br />Field Ins ection <br />Driveway w/ or w/o pipe $140.00 a Paved Frontage $116.00 + 0.53/it. <br />Driveway wlbox Culvert $181,00 Curb, Gutter, Sidewalk $140.00+ 1.161ft. <br />Xi NCROPCHA1RSWa FW=-1eW1aW8%NCR0ACHMW PERW CRNEWAYAocMO) <br />