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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 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 />of this and any attached sheet incl d as general or special III provisions. <br />M a%&4 OH 1 0 I I tom <br />Signature of Applicant !tie e <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None ❑ DirtA Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat PU <br />W1 <br />It 01% <br />3. PIPES: None ❑ Existing—Type 12 <br />Other pipes in neighborhood: Yes kJ No LJ Approaches LPA Cross Drain LJ Size <br />4. HEADWALL: Yes ❑ No a rly <br />5. ASPHALT CnklCDCTM <br />DIKE: Yes ❑ No <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes I No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»>»>»»»»»»»»»»»»»>»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ❑ Commercial ❑ Agriculture Industrial ❑ <br />Paved with Z "Min Depth A.C. over �_ "Min Depth%" A.B. over <br />Notes: <br />2. PIPES: <br />Notes: <br />Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Intel Required Yes ❑ <br />Total Length: (with proposed) <br />3. HEADWALL: Yes ❑ No <br />Ft. and Diameter of Pipe �2 inch(es) <br />No <br />No <br />Total Number of Storm Drain Inlets: <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/$135.00 w <br />Field Ins ection <br />Driveway wl or w/o pipe $140.00 Paved Frontage $116.00 + 0.53/ft. <br />Driveway w/box Culvert $181.00 B Curb, Gutter, Sidewalk $140.00+ 1.16/ft. <br />P!ENGHOAGH MFMSUIazIer Famz-TeirdaleaTNGYOAGHMENT PERMIT D <br />FNEWAY.Ea (0&JB) <br />