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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 helshe 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 <br />4, That in the event any claim oi' such liability is made against the County of San Joaquin or any department, official or employee <br />thereof, he shall defend, indemnify and hold thern 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*ay 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 work described in accordance with all terms, condition and restriction <br />of this and any attached sheet, included as general or special III provisions. <br />Signature of Applicant Title Date <br />EXISTING CONDITIONS <br />1. DRI\/EWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat t <br />3. PIPES: Nonelt. Existing–Type <br />Other pipes in neighborhood: Yes No Approaches Cross E <br />4. HEADWALL: Yes ❑ Nol <br />5, ASPHALT CONCRETE DIKE: Yes ElNqznol <br />G. BARRIERS <br />7. DITCH <br />along Right -of -Way <br />Yes /V No <br />❑ If 1'es: V Style ❑ 2 Point ❑ Other ❑ Width <br />Paved (good) ❑ <br />Depth <br />»>>»»»»»»»»>>»>>»»»»»>»»»»»>I'ERMITS REQUIREMENTS««C« <br />1. DRIVEWAY: SFRQr Commercial El Agriculture F-1 Industrial F'] <br />Paved with HIM <br />2. PIPES: Length of Pipe Required <br />Motes: <br />"Min Depth A.C. over 7 <br />"Min Depth %4' A.B, over <br />Ft. and Diameter of Pipe <br />To be connected to any adjacent driveway pi fle Yes ❑ No <br />Drainage Inlet Required Yes ❑ No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No I[ <br />4, PAVED <br />FRONTAGE: Paved with _ "INin Depth A.C. over_ "Min Depth'/4' A.B. <br />Measuring Feet in length and — ___Feet in width <br />>>'»»>»»»»»»»,°»»>;» <br />Driveway Encroachment Permit base fee____$135.00 <br />=field Inspection <br />Driveway w/ or w/o pipe________$140.00 Paved Frontage________ $116.00 + <br />inches) <br />0,53/ft. <br />Driveway w/bo>; Culvert__- _`$181.00 ❑ Curla, Gutter, Sideuvalk,___�140,OU -i 1,16,!8. <br />P:IEIJCROAONhIENTSIIIasler Porins-Ternpla(es1ENCROACH f/ENT P'cRA41T DRIVE/dal'.dnc (ONO& - - - - - <br />