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THE APPLICANT HERBY CERTIFIES: <br /> 1. Tha,Wshe has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> tomer l t ;and <br /> 2. That,hetshe as the own of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will asswe fel responsibility for all liability for persona,injury or damage to property which may arise out of the work <br /> 4desal-bed above,or 00 may arise out of hisiherfailure to do the work provided herein;and <br /> 4. That in the event any dairn of such liability is made against the County of San Joaquin or any department,official or employee <br /> thereof,he shall:de*W,4ndemnify andhold them and each of them harmless for such claim;and <br /> 5. That work shag be performed b 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 quin 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 if I provisions. <br /> Signature of Applicant Tale Date <br /> »»»»»»»»>y»»»»»»y»»»»»> LD INSPECTION COMMENTS«««««««««««««««««««««< <br /> j)dSlhk OONDITIONS <br /> 1. DRIVEWAY: bone ❑ Dirt [] Gravel 4 Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> o <br /> 2. SLOPING Away from Pavement ❑ Towards Pavement E9 Flat ❑ t' <br /> 3. PIPES: None ❑ Existing-Type <br /> Other pipes in tWoborhood:'Yes 29 No Approaches LJ Cross Drain LJ Size <br /> 4. HEADWALL: Yeas ❑ No <br /> 5. ASPHALT CONCRETE,�31KE: Yes ❑ No <br /> 6. BARRIERS along dight-of-Way <br /> 7. DITCH: Yes IM No ❑ If Yes: V Style ❑ 2 Point Other ❑ Width (I t Depth <br /> »»»»»»»»>»»»»»»»»»»»»»»»>PgFAITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR (. Commercial ❑ Agriculture [3 Industrial <br /> Paved with "Min Depth A.C.over "Min Depth 74"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required 2 3' Ft.and Diameter of Pipe 1 Z7 inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No Z <br /> Drainage Inlet Required Yes ❑ No 0 <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No 2 <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»>y»»»»»»y»»»»»»»»>F E E S««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fes X $90.00 <br /> Field InsDection <br /> ERFUriveway wl or wlo pipe $102.00 ❑ Paved Frontaae $108.00+0.50/ft. <br /> Driveway w/box Culvert $167.00 Curb,Gutter,Sidewalk $105.00+1.03/ft. <br /> Y-TOF04&TEMPLA3 NT'PEAW DFdVMY d"c:(08.W <br />