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fHL APF'I_ICIANT 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. i hat he/she is the owner of the respective property, or is qualified to represent the owner; and <br />3. That hV will assume full responsibility for all liability fior 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 />1. 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*ay at the above <br />indicated site with a valid San Joaquin County Encroachment Permit; and <br />6, That if pernnissio is granted as requested, he agrees to do the wort; described in accordance with all terms, condition and restriction <br />of this any aft d she" ' eluded as general or special III provisions, <br />ignaturqppplicant Title �— --aI� to <br />1, DRIVEWAY; <br />2. SLOPING; <br />3. PIPES <br />4. HEADWALL: <br />INSPECTION (OFFICE USE ONLY)«««««e«««««««««««««< <br />EXISTING CONDITIONS <br />None � Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement Z[ Towards Pavement ❑ Flat ❑ <br />None PIZA <br />-- Existing —Type <br />Other pipes in neighborhood: Yes <br />Yes [INo,fg- <br />5, ASPHALT CC)NCRI.TE DIKE: Yes ❑ No PO <br />- <br />No Approaches Cross Drain Size <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes & No ❑ If Yes: V Style ❑ 2 Point [I <br />Other ❑ Witlth <br />Depth <br />»»»»»>»»»»»»»»»»»»»»>»»»»PERMfTS REQUIREMENTS«««««<e««««««««««««««« <br />DRIVEWAY: SFR F9— Commercial <br />E] <br />Notes: <br />2. PIPES: <br />Notes: <br />Paved with <br />Z <br />Length of Pipe Required <br />Agriculture ❑ Industrial ❑ <br />"Min Depth A.C. over <br />"Min Depth 3/" A.B. over <br />Ft. and Diam�ster of Pip" �� inch(es) <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 />3, HEADWAt.L: Yes ❑ NoL� <br />�. PAVED FRONTAGE: Paved with "Min Depth A.C. over "Min Depth'/<" A,B. <br />Measuring _ Feet in length and �_,_ _Feet in width <br />»»»»>»»»»»»»»»»»»»»»»»»»»»»>FEE;a««««<,«e<«««:«««««««««««««««««< <br />Driveway Encroachment Permit base fee,.. <br />_$135.00 <br />Field Ins section <br />Drivev�ay wI or w/o pipe_ 1 � $121.0 <br />0 <br />Drivewayw@ox Culvert_ ,�$1a1.00 <br />X:IQJCftDACHNENTSILYsk; Form:-TrnP'ateslNCIiOACh'ltl'7r PH2hVT DAIVftYAY.da (uaoo) <br />❑ Paved 1=rontage�^ _ $116.U0 +U.53/ft. <br />[J Curb, Guiter, Sidewaik �_$1a1.U0 + 1.161ft. <br />