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THF APPLICANT HEREBY CERTIFIES: <br />1, <br />2. <br />3. <br />4. <br />5. <br />6. <br />That helshe has read all [he provisions of this application, and that the description included in this application are correct to the best of <br />his/her knowledge; and <br />That he/she is the owner of the respective property, or is qualified to represent the owner; and <br />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 />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 />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 />That if permission is <br />of this and any attacl <br />1. DRIVEWAY: <br />2. SLOPING: <br />3. PIPES <br />4. HEADWALL: <br />nted as requested, he agrees fo do the work described in accordance with all terms, condition and restriction <br />sheet, included as general or special III provisions. <br />icant Title Date ' <br />EXISTING CONDITIONS <br />None ❑ Diit ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) � Paved (good) ❑ <br />Away from Pavement ❑ Towards Pavement ❑ Flat <br />None Existing —Type <br />Other pipes in neighborhood: Yes LLJJ <br />Yes El No RL 01 <br />5. ASPHALT CONCRETE DIKE: Yes ❑ No <br />L <br />No >�Approaches Cross Drain Size <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No [r:_'If Yes: V Style ❑ 2 Point ❑ <br />Other ❑ Width <br />Depth <br />»»»»»»»>»»»»»»»»»»»»»»»»>PGRf1hITS RE4UIRGMENTS««<««««««««««««««««««< <br />1. DRIVEWAY: SFR & <br />F1 <br />Notes: <br />2. PIPES: <br />Notes: <br />` Commercial ❑ <br />Paved with — <br />Length of Pipe Required <br />Agriculture ❑ Industrial <br />in Depth A.C, over `'� <br />"Min Depth'/" A.6. over <br />Ft. and Diameter of Pipe ��� <br />To be connected to any adjacent driveway pipe Yes ❑ No `; <br />Drainage Inlet Required Yes ❑ No �C <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No � �-- <br />4. PAVED FRONTAGE: Paved vdiil+ _ "IViin Depth A.C, over _ "Nin Depth %" h.B. <br />A�easuring _ Feet in length and __Feet in vdidih <br />>>>»>»»»»»»>»»»»»>»»»»»»»»»»»>> F E ES <<<<«««« <br />Dr:vel,v <br />ay Encroachment Permit base fee ,1135.00 <br />Field Inspection <br />Driveway vdl or w/o pipe X1400 <br />00 Paved Frontage fi116.00 + 0.53/ft. <br />Driveway w/laox Culverf_ $'13'1.00 ❑Curb, Gutter, Sidewali; $140.00 +'i.16/ft. <br />FAENGFIOANNd Fill i SWasler Perms-TemplafaslENCRO I,Q:;dEWT PERfdIT ORI'VEVi;I'.Ooe (OE10G) <br />inches) <br />