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THE APPLICANT 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. That he/she is the owner of the respective property, or is qualified to represent the owner; and <br />3. That he/she will assume full responsibility for all liability for persona; injury or damage to property WK 1 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 he performed by the, applicant and/or any representative of the application in the County Right -of -Way at the above <br />indicated site v,/ith a valid San Joaquin County Encroachment Permit; and <br />*90 <br />6, That if permission is granted as requ�fa;;he aorees.to do the vdork described in accordance with all term condition and restriction <br />of this and any aifached�sheet, JnPli'd ms's eDe..4 010 special III provisions, ,/f% , �J <br />E.. Signature of Applicant Title f Date/ <br />'I. DRIVEV��AY <br />2, SLOPING <br />3, PIPES; <br />4, HEADWALL <br />EXISTING CONDITIONS <br />None �, Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />Awayfrom Pavement ❑ Towards Pavement E]Flat( _ <br />None ing —Type <br />Other pipes in neighborhood <br />Yes ElNo 91�- <br />Yes <br />No ,f:;` <br />Approaches <br />Cross Drain <br />Size <br />5, ASPHALT COI'dCRETE DIK<E: Yes ❑ No <br />BARRIERS: <br />7. DITCFiH: <br />along Right -of -Way <br />1'es E]No~ttYes: V Style F-1 <br />2 Point ❑ Other ❑ Width <br />Depth <br />»»»»»»»»»»»»>»»>>»»»»»>»»»PERCt41TS REQUIRECUEC \!'fS««««««««««««««««««««« <br />1, DRIVEWAY: SFR t❑""-��•,Commercial El <br />Agriculture ❑ Industrial ❑ <br />e'. <br />Paved with «r "Mein Depth A.C. over . "Min Depth W A.B. over <br />Nates: <br />2 PIPES; Length of Pipe Required <br />I�Jote�:: <br />^t. and Diameter of Pipe _�`,! <br />To bE: connected to any adjacent driveway pipe `fes ❑ No ��a <br />; • • <br />Drainage Inlet Required 1'es ❑ No <br />Total Length: (with proposed) Total Ntf fiber of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ fdo �� <br />PAVED <br />q, <br />FRONTAGE; Paved with - "hAir Depfh A.C, ovE:r _ " i�1in Depth %' A.B. <br />Measuring ___________ Feet in length an:; _ Feet irl vdidth <br />Driveway E <br />ncroachment Pern;if base fee_____x135,00 <br />Driveway vd/ or w/o pipe <br />Dri'dev�ayw/hog: Culvert <br />$121.00 <br />Field Inspectia;� <br />❑ <br />:!:IEIdC- OAGHI fEhlTShnsiv Poen_ Tan; InlnaiEWCF;uROHIJ'21JT ?ERM111T Cifi V@Vkl'.dor. ioC'�6) <br />Favell Frontage x116.110 + 0.5:3/ft, <br />Curb, Gufier; Sidevdalk __x'i21,00 + 1.161ft. <br />inches) <br />