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J <br />1wIdE APPLICANT HEREBY CERTIFIES; <br />i, That he/she has read all the provisions of this application, and that the description inducted in this application are correct to the best or <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,fshe will assume full responsibility for all lia for persona; injury or damage to properly which may arise out of the worl; <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 departrnent, 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 />G. 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, included as general or special III provisions, <br />et ' Signature of Applicant Title <br />1. DPJVEVVAY <br />2. SLOPING: <br />3, PIPES: <br />4. HEADWALL: <br />EXISTING CONDITIONS <br />None ❑ Dirt ❑ Grave^ Aggregate Base ❑ Paved (poor) ❑ Paved (goo <br />r <br />d) ❑ <br />Away from Pavement ❑ Towards Pavement ❑ <br />None A Existing — Type <br />Other" i es in neighborhood: <br />Yes ❑ No ,( <br />Flat, <br />Yes <br />No <br />�; <br />Approaches <br />Cross <br />Drain <br />Size <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No�a <br />6. BARRIERS <br />along Right -of -/Nay <br />DITCH <br />Yes El No If Yes <br />V Style ❑ 2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERk/i I'i"S REQU IR EM Ef QTS««««««««««««««««««««« <br />1. DRIVEWAY: SFR 40 <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A. C. over. "f "Min Depth 4' 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 1'es ❑ <br />Total Length: _ (with proposed) <br />(Votes: <br />�,. HEADWALL: Yes ❑ Nod, <br />4, PAVED FRONTAGE: Paved with <br />Meas ring <br />Ft, and Diai7)eier of Pipe „�;`�� inches) <br />IV 0 <br />No T� <br />Total Number of Storm Drain Inlets: <br />"Min DeF;th A.C.. over <br />Feet in !engtl) and __ <br />" IUin Depth'Q' A.B. <br />=eet ire width <br />»»»>»»»»»»»»»»»»»»»> »»>»»»»>;x> FEES «««««« <br /><«G G<GG<:G<G«<G<««<G«:< <br />Driveway Encroachment Pern•iit base fee $135,OU <br />Field h -is =ction <br />Drivewayivl or w/o <br />pipe $140,60 <br />Drive way v��/box Culver $181.00 <br />P1E!CkuL6HAfEb!T' IJ�sler Riims4emplale:le4i]ROFIC;i6alE4iT PPoiiidfi RF;IVL=VdFi.uoc tUalUf,) <br />❑ Paved Frontage $116,OU + 0.53/ft. <br />[] Curb, Gutter, Sidewalk $140,OU + 1,'16/ft. <br />