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THE APPLICANT HEREBY CERTIF41ES: <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. Tliat he/she will assume full responsibility for ail liability for persona; injury or damage to property which may arise oul 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 depailmUM, 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 represenkar an of the application in the Country Right of -Way at the above <br />indicated site with a valid San Joaquin County Encroachment Permit, and <br />G. That kf permission is granted as requested, h re t¢ o the work described in accordance with all terms, condition and restriction <br />of this and any attached sheet, includedas •a res eclat III provisions. <br />Aoi <br />Signature of Applicant TitJ to <br />»»»»»»»>»»»»»»»»»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />1. DRIVEWAY: <br />2. SLOPING: <br />3, PIPES: <br />4. HEADWALL: <br />hlone Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Away from Pavement ❑ Towards Pavement ❑ <br />None M_ Existing — Type <br />Other pipes in neighborhood: Yes Lj <br />Yes ❑ No 0 <br />5. ASPHALT CONCRETE DIKE, Yes F-1 <br />6. BARRIERS: along Rigl$of-Way <br />7. DITCH: Yes ❑ No q If Yes <br />Flat X] <br />No Approaches Cross Drain Size. <br />V Style ❑ 2 Point ❑ Other ❑ Witlth <br />Depth <br />»»»»»»»»»»»»»»»>»»»»>» >»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br />1. DRIVEWAY <br />Notes; <br />SFR ❑ Commercial X❑ Agriculture ❑ Industrial ❑ <br />Paved with 3.5 "Min Depth AL. <br />2. PIPES: Length of Pipe Required <br />Notes; <br />over <br />4.5 "Min Depth'/A" A.B, over <br />Ft, and Diameter of Pipe __ 1'9 <br />To be connected to any adj <br />Require <br />acent driveway pipe Yes ❑ No <br />Drainage Inlet d 1'es ❑ No A <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL; Yes ❑ No <br />inches) <br />�. <br />PAVED 1=RONTAGE: Paved with �__ "Min Depth A.C, over _ "Min Depth'/;' A.B. <br />Measuring Feet in length and Feca in width <br />»»»»»»»»»»»»»»»»»»»» >»»»» >»» F E F. S «««««««««««««««««««««<««<<. «<<< <br />Driveway Encroachment Permit base fee_____ $135.0 <br />Field Ins ecfion _ <br />TDriveway <br />Drivewaww/ or w/o plpe__A_ iT <br />$140.0 <br />ww/box Culvert.......... <br />xuait.Ho,�ri��eemami.,,lc: Pmmc-rrmplalm�Ellf.HOACHl��rrrr�iivrrnr+ivwreva<c�an�oc� <br />Total: $275.00 <br />Pave <br />d f=rontage�_�____$116.00 •+ 0.531ff. <br />Curb, Gutter, Sidewalk ___^$121.00 •t 1.16lft. <br />