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THE APPLICANT HEREBY CERTIFIES; <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 properly, 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 properly 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. <br />That In the event any claim of such liability 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 />51 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 />8, That If permission Is granted as requested Jae n3 s to do the work described In accordance with all terms, condition and restriction <br />of this and any attached shaeff eror special III provisions. <br />E <br />LZ -d7 -2L <br />gnat pp can e a e <br />»»»»»»>»»»>»»>»»»»»»»»FIELD INSPECTION OFFICE USE ONLY)««««««««««««««««««« <br />EXISTING CO DITIONS <br />1. DRIVEWAY; None [,]� Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ <br />2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat [d <br />3. PIPES: None Exlslin%—Type <br />Other pipes In neighborhood: Yes I I No LJ Approaches LJ Cross Drain L Size <br />4, <br />HEADWALL; Yes ❑ No <br />❑ <br />❑ <br />Drainage Inlet Required <br />5, <br />ASPHALT CONCRETE DIKE: <br />Yes <br />❑ <br />No [� <br />6, BARRIERS: <br />7. <br />along Rlght•of•Way <br />DITCH: <br />Yes EJNo I If Yes: V Style El <br />2 Point ❑ Other ❑ Wldfh Depth <br />»»»»»»»>»»»»»»»»»»>»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br />1, DRIVEWAY: SFR [A Commercial ❑ Agriculture ❑ Industrial ❑ <br />Paved with 2 "Min Depth A.C. over 'i "Min Depth'/;' A.B, over <br />Notes: <br />2. PIPES; Length of Pipe Required <br />Notes: <br />Ft. and Diameter of Plpe NH Inches) <br />To be connected to any adjacent <br />driveway pipe Yes ❑ <br />No <br />❑ <br />Drainage Inlet Required <br />Yes ❑ <br />No <br />❑ <br />Total Length: <br />(with proposed) <br />Total <br />Number of Storm Drain Inlets: <br />3. HEADWALL: Yes ❑ No [7j <br />4, PAVED FRONTAGE; Paved with 2 "Min Depth A.C. over 4 " Mln Depth'/;' A.B. <br />Measuring Feet In length and Feet In width <br />>»»»»»»»»»»»>»»»»»»»»»>»»»»> F E E S ««««««««««««««««««««««««««<< <br />Driveway Encroachment Permit base foe $140.00 <br />le Dr veway wl or w/o <br />Alpe $140.00 <br />Driveway w/box Culvert $101.00 <br />%NiNI%ININNI4tl:NlMOW 15xnn�TalnMlnN'.MAN, Ni;I IM:Nf NlI1NlI ININI.WAYx4xl (YM1A) <br />Paved Frontogo $118.00 + 0.531ft. <br />Curb, Gutter, SI ewa $140.00 + 1.161ft. <br />