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THE APPLICANT HEREBY CERTIFIES; <br />I, That he/she has read all the provisions of this application, and that the description included in this application are correctto 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; arld <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 />61 That if per rIission is granted as requested, he ages to do the work described in accordance with, all terns, condition and restriction <br />oft is and n� attach ed6wh et, included as gen ral or special III provisions. <br />`felta F�'l IA u e`=h Q <br />1 Signature of Applicant Title Dat& <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None Q Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />3. PIPES: None,Kk Existing—Type <br />Other pipes in neighborhood: Yes `4 No Lj Approaches , . Cross Drain Size F �i <br />4. HEADWALL.: Yes No ❑ <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No ``- <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ,) No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»» PERM ITS REQ U I REM ENTS«<<<<<<«««««««««««««« <br />1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over d' "Min Depth %" A.B. over <br />Notes: <br />2. PIPES: <br />Noies: <br />Length of Pipe Required <br />Ft. and Diameter of Pipe r� ,'ir <br />To be connected to any adjacent driven✓ay pipe Yes ❑ No [t <br />Drainage Inlet Required 1'es ❑ No '1`] <br />Total Length: _. (with proposed) Total Number of Storm Drain Inlets: <br />3. HEAQINALL: 1'es 6X� No ❑ <br />PAVED FRONTAGE: Paved with <br />M <br />4. <br />easuring <br />»»»»»»»»»»»>•»}»»:>» <br />Dri!/evday Enaoachment Permit base fee___;�135.00. <br />Field Ins ection <br />tDriveway wl or w/o pipe_ $121.00 <br />Dnvl=Inlay vJ/box Culvert ----_____$181.00 <br />RIEJJOROhCHIAEIdT^alMasle: Fouus=fertplaleslE6CR0ACHWENT PEF.A41T OW1'EVVAY.doc (OSIoO) <br />"f�'tin Depth A..C, over ___ "Min Depth'/�' A.B. <br />Feet ir) length and _ _JFeet in width <br />Pay/ed Frontage _ $116.00 + 0,53/ft. <br />�. Curb, Gutter, Sidevdalk. _121.00 + 1.16/ft. <br />I <br />