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FHE APPLICAIN f HEREBY CERTIFIES: <br />1, I hat he/she has read all the provisions of this application, and Ilia[ the descriplion 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 repro. -sen( the o�,vner; and <br />3. That he/she will assume full responsibility for all liability for persona; injury or damage to property which rnay 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 />(hereof, he shall defend, indemnify and hold them and each of them harmless for such claim; and <br />5. Thal work shall be 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 />G, That I(perniission is granted as requested, he agrees to do the work described in accordance with all termscondition and ti <br />of (his and any attached sheet, included as general or special III provisions, , restricon <br />1. DRIVEWAY <br />2. SLOPING <br />3, PIPES: <br />4. HEADWALL; <br />6. BARRIERS: <br />7. <br />along Right -of -Way <br />DITCH: <br />ate <br />EXISTING CONDITIONS <br />None ❑ Dirt ❑ Gravel � , Aggregate Base ❑ Paved (poor) ❑ Paved (good) [J <br />Away from Pavement ❑ <br />None ik, Existing - Ty <br />Other pipes in neighborho <br />Yes ❑ No 9. <br />e <br />5, ASPHALT CONCRETE DIV <br />E; Yes ❑ No <br />Toavarcls Pavement F1 Flat <br />_ <br />Yes E7 INlo & If Yes: V Style El <br />2 Point ❑ Other ❑ Width <br />Depth <br />»>»»»»»»»»»»»»»» »»»»»»»»> PER fVi IT S R EQU IR ENI E N'I'S ««««««««««««««««««<,<«« <br />1. DRIVEWAY: SFR, Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2' "Min Depth A.C, over "Min Depth'/" A.B. over <br />Notes: <br />2, PIPES: Length of Pipe Required _ FL and Diameter of Pipe __,� <br />To be connected to any adjacent driveway pipe Yes ❑ Ncfi Q, <br />l <br />Drainage Inlet Required Yes ❑ No,[r <br />I Olaf Length: (with proposed) Total Number of Stoun Drain Inlets: <br />Notes: <br />inrh(es) <br />3. HEADWALL; Yes ❑ No <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 />Driveway Encroachment Permit baso (ee_ $1135.00 <br />f�ieltl I ns�eciion <br />nriveway wl or wlo pipe--_-- _$140.00 <br />$018100 <br />Driveway wlt ox 00 <br />N�tucito��emlfnlSu!eaaF�oes <br />�euuiafsma:r�nrmm�;rvrn��rtuaiutvrtv,,gn;,,ce� <br />_ _ Paved Frontage,___ ___ X116,00 .i. U.53IfL <br />a Curb, Gutter, 5ide�r�allt_ _y�140.00 �1,'16/(f. <br />