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THE APPLICAN i HEREBYCERTIFIES: <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 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 in the event any claim of such liaty 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 with a valid San Joaquin County Encroachment Permit; and <br />6. That if permission is granted as requested, he agrees to do the vdorlc described in accordance with all terms, condition and restriction <br />of this and any attached sheetincludedas general or special III provisions. <br />/ L ��14n 0 <br />Signature of Applicant Title (f ate <br />EXISTING CONDITIONS <br />0A le <br />1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor i' <br />orf <br />Paved <br />2, SLOPING: Away from Pavement E]Towards Pavement ❑ Flat (E[j <br />3, PIPES: None r] Existing – Type <br />Other pi' es in neighborhood: Yes Lj No Approaches Cross D <br />4. HEADWALL: Yes F]No <br />5, ASPHALT CONCRETE DIKE: Yes F-1Not17 <br />6, BARRIERS: along Right -of -Way _ <br />7, DITCH: Yes ❑ No AJ, If Yes <br />, <br />(good) ❑ <br />V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERfViITS REGUIREfi4ENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR ❑ Commercial r2l <br />' <br />Paved with "kk <br />Notes: <br />2. PIPES: Length of Pipe Required <br />Agriculture ❑ Industrial ❑ <br />"Min Depth A.C. over. C474'gt! <br />I <br />I�;otes: <br />be connected to any adjacent driveway pipe Yes ❑ <br />Drainage Inlet Required Yes ❑ <br />Total Length: _ (with proposed) <br />3. l-IEADINALL: Yes ❑ luo ��+ <br />"Min Depth'/�" A,B, over <br />Ft. and Diameter of Pipe _ ,'`� <br />Total Number of Storm Drain Inlets: <br />inches) <br />4. PAVED FRONTAGE: Paved with "Min Depth A,C, over "Min Depth'/" A.B, <br />Measuring _ Feet in length and — Feet in width <br />»»»»»»»>>»»»»»»»»»>> »»»»»»»»»FEES «««««««<•: ««««««« <«««««««««««< <br />.- t7 <br />Driveway Encroachment <br />Permit base fee_ 5135.00 <br />L;ield Inspection f° <br />Driveway wil or w/o pipe $140.00 <br />u Driveway w/box Culvert $181.00 <br />F:IEPIOfiOACHA4ENTS1%:actor Forms-Teff�FlalasLRCROACkAIEFITFERFAIT 7RI'✓EWh1'ax (OMB) <br />❑Paved Frontage $11 G.UO + 0.53/ft. <br />Curb, Gutter, Side��talk $140,00 + 1.'16/ft. <br />