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THE APPLICANT HE=REBY 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 thein 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 -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 wort( described in accordance with all terns, condition and restriction <br />of thjs ane3ny attached sheet, included as,general or special III provisions. <br />a� <br />SIgnatn�f La pplicant Title ' -- - - I -A- ._l ate- <br />»»»»»»»»»»»»»»»»»»»»>PIELD <br />EXISTING CONDITIONS <br />1. DRIVEWAI': None ,(� Diit ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None X Existing - Type <br />Other pipes in neighborhood: Yes Lj No 14 Approaches H Cross Drain Lj Size <br />4. HEADWALL: Yes ❑ Noo <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No 4 <br />6. BARRIERS: <br />i�i]iiN:F <br />along Right -of -Way _ <br />as ❑ Nolov if Yes: V Style ❑ <br />2 Poiret ❑ Other ❑ Width Depth <br />»»»»>»>»»»»»>»»»»»»»»»»»»>PERMITS REQUtREMENTS««««««««««««««««««<c«« Vr <br />1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with Z "Min Depth A.C. over_? "Min Depth W A.B. over <br />Notes: <br />2. PIPES: Length of Pipe Required _ ^ Ft. and Diameter of Pipe _� <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />Notes: <br />inches) <br />3. HEADWALL: Yes ❑ NdIYT <br />4, PAVED FRONTAGE: Paved with _ _ "Min Depth A.C. over " Min Depth W A.B. <br />Measuring Feet in length and _ Feet in width <br />»»»»»»»»»»»»»»»»>»»»»»»»»»»>PEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $140.00+6�., /JD <br />Field Insection (y <br />All iveway w/ or w/o pipe $140.00 <br />Drivewayw/box Culvert $181.00 <br />%IENCROALNM£NiSV.iasltt FwmsTe"gkteslENCROACHAfENr PEPI.YIMtNEWAYdoc(OBNS) <br />Frontage <br />®Paved <br />Curb, Gutter, Sidewall(_ <br />_$116.00+0.53/ft. <br />$140.00 <br />+ 1.16/ft. <br />