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r <br /> THE APPLICANT HERE Y CERTIFIES: <br /> 1, That Itabhe reel ak provisions of this action,and that the descr ion included in this application are correct to the best of <br /> him <br /> 2, That helsh�is me owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/ * assume full responsibility for all fiabky for persona;injury or damage to property which may arise out of the work <br /> descried alone,Of wjdmaybe out of It her faWre to do the work provided herein;and <br /> 4. That in the sant anyclaim of such liability is made against the County of San Joaquin or any department,official or employee <br /> thered,he s� , and h6ld 1hem and each of ihetii barmtess for such claim;and <br /> 5. That work sI�O be perf medthe applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated skalI with a San�tiin County Encroactimerit Permit;and <br /> 6. That if perm sin is granted as reg?uesled,he WW to do the work described in accordancewith all terms,condition and restriction <br /> of this attached s or special fit provisions. <br /> A) <br /> Mure of Applimint TMe Date <br /> »»»»»>y»»»»�»»»»>y»»»»»»REL,D 11 CTM. C-OMMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br /> F.XfR'ftN CE�3Ci`tt)N5 <br /> 1. DRIVEWAY: None [ ] Dirt 0 Gravel Aggregate Base ❑ Paved(poor) ❑ Paved(good) <br /> 2. SLOPING: Away tOm Pavement Towards Pavement ❑ Flat <br /> 3. PIPES: None ["Exist-Type <br /> Other pipes In : Yes No LJ Approaches U Cross Drain U Size <br /> 4. HEADWALL: Yes No <br /> 5. ASPHALT CONCRETE 01KE: Yes ❑ No [+ <br /> 6. BARRIERS: along Right-of-w, <br /> 7. DITCH: Yes Not Yes: V style 0 2 Point ❑ Other ❑ Width Depth <br /> »»y»»»»»»>>»�»>>»»»>»>>>>»»>>> >>PEIMM REOUIREMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br /> 1. DRIVEWAY: SFR 4KCommerc4al ❑ Agriculture ❑ Industrial ❑ <br /> Paved with 'Min Depth A.C.over .'Min Depth 3/4"A.B.over <br /> Notes: ' ... ! <br /> 2. PIPES: length of Pipe Required 4 " R.and Diameter of Pipe ; ''J inch(es) <br /> To be connected to any adjacent driveway pipe YesNo <br /> Drainage Inlet Required � � Yes 0 No [�^' <br /> Total Letrgth. (with proposed): Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [ ,,r, <br /> 4. PAVED FRONTAGE=: Paved with °Min Depth A.C.over °Min Depth 31<°A.B. <br /> I Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»>y»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee-$90100 <br /> Field Inspection <br /> Driveway w/or w/o pipe $102.00 8Paved Frontage $108.00+0,50/ft. <br /> LJ Drivewayw/box Culvert $167.00 Curb,Gutter,Sidewalk $105.00+1,03/ft. <br /> Y:IFOPMS d TEMPLATESENOfiOAWWNT PEPMT ORM-ftY.dw(OB.R <br />