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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 tha best of <br /> his/her knowiedge;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,41 assume full responsibility for all liability for persona',injury or damage to property which may arise out of the H ork <br /> described above,or which may arlse out of hWher failure to do the 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 /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That%vork 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 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 <br /> �attacheddssheet,included as general or special ill provisions. <br /> Signature sof pii ant CX-, fie `t ZM ae <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION <br /> EXISTING CONDITIONS <br /> 1, DRIVEWAY: None ❑ Dirt ❑ Caravel x Aggregate mase ❑ Paved(poor) 0 Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Fiat ❑ <br /> 1 PIPES: None Existing—Typa <br /> Other ipes in neigh hood: as No 0 Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DiKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way _ <br /> 7. DITCH: Yes ❑ No W If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»,»`»»»»»»»»»»PERMITS REQUIREMENTS«<�;«««<et«««««««««««<.t«« <br /> 1. DRIVEWAY: SFRX Comme�rccial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with !!"Min Depth A.C.over "Min Depth 1/4"A.B.over <br /> Notes: <br /> 2. PiPES. Length of Pipe Required Ft.and Diameter of Pirie inches) <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 Storm Dain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ NoA <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth'!."KB. <br /> Measuring Feet in length and _Feet in width <br /> a»a»»a»»»»>a>`.�»»S>}»}a>?i»»»>}}»»»>:}`.✓?���5«{CCC«CC<CGCC:{{<C{<G<C<{�'<C««C<C<G{CC«GCt{.�{CCC. <br /> Driver,,ay Encroachmert r-0rmit base fee$135.00 <br /> 3 d Ins ecti0n <br /> Driveauay w/or w/o pipe _____$121.00 k.'Z Paved Frontage $116.00+0.53/ft <br /> Driveway w/box Culvert $1$1.00 Curb,Gutter,Sidewalk_ $121.00+1.161ft. <br /> ��:CBdTRAt�RV10E5U�knlC�V�l9SV.l'Jk'+(ASTER.PSENCR��N,IIC�rrl�'R'i�TDRh�i°IAY.pOC (OFU�31 r'ageiof� <br />