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THE APPLICANT HEREBY CERTIFIES: <br />'l. That he/she Has read all the provisions of this application, and that [lie. 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 which may arise out of [fie work <br />described above, or which may arise out of his/her failure to do file 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.harmiess 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 -Way at the above <br />indicated site with a valid San Joaquin County Encroachment Permit; and <br />6. That if ission is gr s requested, he agrees to do the work described in accordance with all terms, condition and restriction <br />of this any alta d shd t, included as general or special III provisions, <br />xo� =)Z9 2 0 <br />Sigkhrure of Ap cant Title i L&te <br />EXISTING CONDITIONS <br />1, DRIVEWAY: None �j Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from .Pavement ❑ Towards Pavement ❑ Flat jP <br />j <br />3. PIPES: None 14 Existing — Type <br />Other pipes in neighborhood: Yes No Approaches <br />4. HEADWALL: Yes ❑ No K <br />5. ASPHALT CONCRETE DIKE; Yes ❑ No [� <br />6. BARRIERS: along Right -of -Way <br />7. DITCH: Yes ❑ No 91 IT Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY; SFR Commercial ❑ Agriculture ❑ Industrial <br />❑ <br />Paved. with "Min Depth A.C. over `t "Min Depth Y4" A.B, over <br />Notes: <br />2. PIPES:. <br />Igotes; <br />Length of Pipe Required <br />To be connected to any adj1acent driveway pipe Yes ❑ <br />Drainage (nletRequired Yes ❑ <br />Total Length: (with proposed) <br />IJo <br />IJo <br />To <br />3. HEADWALL: 'Yes ❑ No ,� <br />4. PAVED FRONTAGE, Paved with "Min Depth. A.C: over "Min Depth %4' A.B, <br />INA <br />Fk and Diameter of -Pipe /Uinch(es)5 <br />Number of Storm Drain Inlets: <br />Feet in Iengih and Feet in width <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>4 <br />Driveway Encroachment <br />Permit base fee ,$135.00 � <br />Fi. Id Ins ection � <br />Driveway wl or w/o pipe $1410.00 ❑ Paved Frontage $116000 + 0,53/fl, <br />Drivewayw/box Culvert_____y1d1,00 ❑ Curb, Gutter, Sidewalk: _$140.00+1.16/fi. <br />P,Ir11CROkCIfI(EI ITSL11,r,1m f-orms-f¢ngAalaslEl ICI;OACNI,LtJT PF,f h7i PFNE1.'!Al'.dtlr. (07fJ9) <br />