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THE: APPLICAI'\F1 HEREBY CERTIFIES; <br />i, Vhaf 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 11 she will assurne full responsibility for all liability for persona; injury or darnage 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 />4. That i11 the event any claim of such liability is rnade 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-Vl�ay 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 atta d sheet, irAte6d as general or special III provisions, <br />)01 <br />�Si na ure of Applicant Title P <br />�` g Pp ate <br />EXISTING CONDITIONS <br />1. DRIVEWAY: None ❑ Diit ��`� Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br />�.c <br />3. PIPES: None Existing — Type fit_ <br />Other I,,N„s in neighborhood: Yes Ll No Approaches tij Cross 1 <br />4. HEADWALL: Yes ❑ No <br />5• ASPHALT CONCRETE DIKE: Yes ❑ No 0 <br />G• BARRIERS: <br />along Right -of -/Nay <br />7, DITCH: Yes Q No <br />If Yes: V Style ❑ 2 Point ❑ Otlmer ❑ Width <br />Paved (good) ❑ <br />Deptlm <br />»»»»»»»»»»»»»»»»»»»»»»»» P E RfVIlTS Rt;G? UI RE MEfVTS««««««««««««««« <«««««< <br />1, DRIVEWAY: SFR M�X"` <br />Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with� "Min Depth A.C. over ``'- 0 "loin Depth'/'" A.B. over <br />(Votes: <br />2, PIPES: Length of Pipe Required <br />To be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: _ (with proposed) <br />Notes: <br />3, HEADWALL: Yes ❑ No <br />4. PAD F <br />'✓ERONTAGE: Paved with <br />I+beasuring <br />. Ft. and Diameter of Pipe <br />No ❑. <br />No El <br />Total Number of Storm Drain Inlets: <br />"1�4in Depth A.C, over <br />=eet in length and _ <br />"Min Depth 3�4 A.B. <br />=eet in v✓idth <br />inches) <br />Driveway Encroachment Permit base fee <br />Field Inspection <br />51 Drivewayw,l <br />or v✓/o pipe. <br />.."brivev✓ay v✓!bo>: Ci -//vert. <br />P ,II1 <br />�r <br />>140.00 �`' <br />618'1.00 <br />F':IliliC:F.PACFIA4EP� i Sl11nr.:;r Fnmrs-i emplaleslEi�!CRO.r,r;.IFIeIJ i PekF/r DF;d/EVdAl�.rioc (06142! <br />Paved Frontage__ $11G.00 +U.53/ff. <br />_ Curb, Gutter, Side�n✓alk__^_-$140.00 + 1.16la. <br />