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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 property,or is qualified to represent the owner;and ch may arise out of the vdorlc <br /> or <br /> e to <br /> 3, That he/she assume or which/may responsibility <br /> �sed out of hisfor l/herbfiailure tfor o do the work prow provided here nanproperty whi y <br /> described above, <br /> 4, That in the event any claim of such liability is Made inst the of them County rm ess fo asuchof San in or claim adnedpartment,official or employee <br /> thereof,he shall defend,indemnify a hold them and <br /> eac5. <br /> 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 /> That if permission is granted as requested,he agrees to othe Iwprovisions,work described in accordance with all terms,condition and restriction <br /> 6. of this and a ttached sheet,included as general or special / <br /> c c 4 ate <br /> Signature of App am T it1C <br /> f . <br /> »»»>»»»»»>»>»»»>»»»>�»»»>FIELD�I STING CONDITIONS.® iNTS««««««««««««««««««««« <br /> Dirt/141 Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 1. DRIVEWAY: None ❑ _ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat ]n <br /> None ❑ Existing—Type "� t' <br /> 3. PIPES: to A proaches :J_ Cross Drain Size <br /> Other pipes in neighborhood: Yes n p . <br /> 4. HEADWALL: Yes ❑ Nod, <br /> 5. ASPHALT CONCRETE DIKE:,Yes EJ No <br /> 6. BARRIERS: along Right-of-Way •• ' <br /> 7. DITCH: Yes [X No ❑ If Yes: V Style ❑ 2 Point _ <br /> Other ❑ Width Depth �= <br /> »DITCH:»»��»»»»»>»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> Commercial ❑ Agriculture El Industrial <br /> 1. DRIVEWAY: SFR [] "Min Depth 3/4`A.B.over <br /> Paved with ¢ "Min Depth A.C.over p <br /> Notes: <br /> Ft.and.Diameter of Pipe <br /> t2` inch(es) <br /> 2. PIPES: Length of Pipe Required <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> ❑ No <br /> Drainage Inlet Required (with Yes proposed) Total Number of Storm Drain Inlets: <br /> Total Length: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No "Min Depth 3/<"A.B. <br /> 4. PAVED FRONTAGE: <br /> "Min Depth A.C.over--. Feet in width <br /> Measuring Feet in length and <br /> »;»»»»»»»»»»»»»»»»»» »»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $135.00 <br /> Field Inspect Paved Frontage $116.00+0.53/ft. <br /> 21.00 ® Curb,Gutter,Sidewalk—­3 121.00+1.16/ft. <br /> Driveway w/or w/o pipe $181 TO <br /> LJ Driveway w/box Culvert <br />