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THE APPLICANT HEREBY CERTIFIES; <br />i. 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 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 It <br />4. That in the event any claim of such liability is made against the County of Sat` Jpaquir) pr any dePaftlnent aj~frcial`Or g1VIRloyed,4*' <br />thereof, he shall defend, indemnify and hold them and each of them harmless IQs c h cairn and} ",' <br />5, That work shall be performed by the applicant and/or any representgK I e1offlt ppplicatior in tVe Cpunty Right -of -Way at the above <br />indicated site with a valid San Joaquin County Encroachment Permit; and' " <br />6, That if p�,x�a' ion is granted se , he agrees to do the work described in accordance with all. jerms; condition and restriction <br />of this and a y ttached she t, cl ed s general or special III provisions: "' j " R „' �y <br />9 goo OMO �../ <br />Signature of AonZantTilik Date <br />»»»»»»»»»»»»»»»»»»»»> F IELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CONDITIONS <br />r• r <br />1. DRIVEWAY: None ❑ Dirt TM Gravel ❑ Aggregate Base ❑ Paved (poor) ❑, ,-Paved.hood) ❑ ; <br />2. SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ ^ <br />3. PIPES: None ❑ Existing — Type . (Z C k^A-FSJ/ <br />Other pipes in neighborhood:' Yes No Approaches ]. Cross Drain Size <br />4, HEADWALL: Yes ❑ No <br />5, ASPHALT CONCRETE DIKE: Yes ❑ No Pq <br />6, BARRIERS: along Right -of -Way <br />7. DITCH: Yes _ No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br />»»»»»»»»»»»»»»»»»»»»»»»» PERM <br />IJotes: <br />ITS REQ UI R ENI ENTS««««««««««««««««««««« <br />1, <br />DRIVEWAY: <br />SFR �_ Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with "Min Depth A.C. over "Min Depth'/' A.B. over <br />2, PIPES: Length of Pipe Required Ft. and Diameter of Pipe <br />To be connected to any adjacent driveway pipe Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Sto, m Drain Inlets: <br />Notes: <br />inches) <br />3, f-IEADWALL: Yes ❑ No . <br />4, PAVED FRONTAGE: Paved with "Min Depth A.C. over " Min Depth 3/4" A.B. <br />Measuring _ Feet in length and Feet in width <br />>>>>>>>»»>>>>>>>>>>> >>>>>>>>>>>,>>>>>>>>>>>>>t>>>>>>>> «««««««««« <br />It <br />Driveway Encroachment Permit base fee $ � <br />Field Inspection <br />r. Driveway w/ or w/o pipe $It#64f Paved Frontage $116.00 .F 0.53/it. <br />Driveway w/box Culvert $181.00 ❑ Curb, Gutter, Sidewalk_ $121.00 + 1.16/ft. <br />X:IEkCRC4CH:dENT�>iM�sler Parols-TumolaleslENCR0.4CHM14E11T PERIdI'� ORIVEJJf,1'.duc (OEIJC) <br />