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THE APPLICANT HEREBY CERTIFIES; 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 his/her knowledge; and 2. That be/she is the owner of the respective property, or is qualified to represent the owner; and 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 described above, or which may arise out of his/her failure to do the work provided herein; and 4. That in the event any claim of such liability is made against the County of San Joaquin or any department, official or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; and 51 That work shall be performed by the appplicant and/or any representative of the application in the County Right -of -Way at the above Indicated site with a valid San by County Encroachment Permit; and 6. That if permission is granted as requested, he agrees to do the work described in accordance with all terms, condition and restriction of this and any attached sheet, Included as general or special III provisions, F Signature of Appl cant Title a e >»»>»»»»»>»>»>»»>»>»»»»»FIELD INSPECTION (OFFICE USE ONLY)««««««««««««««««««« EXISTING CONDITIONS 1. DRIVEWAY: None d Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved (poor) ❑ Paved (good) ❑ 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 114 3, PIPES: None [A Existing — Type Other pipes In neighborhood: Yes No Approaches Cross Drain Size 4, HEADWALL: Yes El No LSI 5. ASPHALT CONCRETE DIKE: Yes ❑ No Uf 6. BARRIERS: along Right-of-W--aiy 7, DITCH: Yes El No No If Yes; V Style ❑ 2 Point ❑ Other ❑ Width Depth »»>»>»>»»>»»>»»»»»»»>»»»>»>PERMITS REQUIREMENTS««««««««««««««««««««« 1. DRIVEWAY: SFR Uf Commercial ❑ Agriculture ❑ Industrial ❑ Paved with 7_ "Min Depth A.C. over Lk "Mtn Depth %" A.B. over Notes: 2. PIPES: Length of Pipe Required N N Ft. and Diameter of Pipe A/A inch(es) To be connected to any adjacent driveway pipe Yes ❑ No d Drainage Inlet Required Yes ❑ No Total Length: IVA (with proposed) Total Number of Storm Drain Inlets: Notes: 3. HEADWALL: Yes ❑ No [7J 4. PAVED FRONTAGE: Paved with "Min Depth A.C, over "Min Depth %" A.B. Measuring Feet In length and Fedhin width »»»»>»»»»»»>»»»»»»»»»>»»>»»»»FEES «««««««««<««««««««««««« Driveway Encroachment Permit base fee $140.00 laid Ins ec ton Driveway w/ or w/o pipe $140,00 a Paved Frontage $116.00 + 0.53/fl. DrivewaywlboxCulvert $181,00 Curb, Gutter, Sidewalk $140:00+1.16/ft: X'f IItpMCIlAE1119Me4u FamsTmyY�uEAtN¢4CHAFM PENN1f ONVflVAY.tloo 1 Wk1