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THE APPLICANT elf CEFITIFIES <br /> 1 Tt :balshe has rel all the provisions of this application,and that the description included in this application are correct to the best of <br /> h' `, . <br /> 2, ThatbaMs isthe owner.of the respective property,or is qualified to represent the owner;and <br /> 3. That helms will assume Urrapponsibifty for 80 IiWlity for persona;injury or damage to property which may arise out of the work <br /> out of htsr failure to do the work provided herein;and <br /> 4. That in#ie eft any art of smh'liability is made against the County of San Joaquin or any department,official or employee <br /> # �. cfentnityy # ttart and each of them harmless for such claim;and <br /> 5. That vibtk shall be p bored by the applicant andfor any representative of the application in the County Right-of-Way at the above <br /> ind ated slte ,a valid San Joaquin>Cointy-Encroachment Permit;and <br /> 6 That ifperm:isgrafi �te <br /> as reqd,he agrees to do the work described in accordance with all terms,condition and restriction <br /> ' <br /> of inckideclas gen6mt or special III provisions. <br /> '2b `8�L <br /> of,;. t tjie `i--[Yate <br /> y»>y,»»>>>>>>>>>>>>�,>>»»»>>»»>>»»>F ELL INSPECTION COMMENTS«««««««««««««««««««««< <br /> E)OSTING CONDITIONS <br /> 1. DRIVEWAY: None j lrt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING Away from Pavement. Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None E' xisting—Type <br /> Olt. � Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE Yes ❑ No <br /> 6. BARRIERS: aloe Might-of-Way <br /> 7. DITCH: Yes "'lNo 1f Yes: V 22 Point Other ❑ Width � I A Depth <br /> � ❑ � Lam" [I <br /> »»»»»,»»» »»»»,»»>»»>»»>yy»»PERNTS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR wyoommetcial ❑ Agriculture ❑ industrial <br /> Paved with "Min Depth A.C.over "Min Depth 3/4'A.B.over <br /> Notes: ' COAr . <br /> 2. PIPES: Length of Pipe Required i ` Ft.and Diameter of Pipe ! l inch(es) <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 Drain Inlets: <br /> Nates: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRN AGE: Paved with "Min Depth A.C.over "Min Depth 3/4"A.B. <br /> r Measuring Feet in length and Feet in width <br /> >>»»»>>»»>>>»»»>»»»»»»»»»y»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroaent Permit base fee $90.00 <br /> M <br /> ection $102.00 Paved Frontage $108.00+0.50/ft. <br /> riveway w/or w/o pipe Curb,Gutter,Sidewalk $105.00+1.03/ft.riveway w/box Culveri $167.00 <br /> Y.-MSMS&TEMPLATESYENCROACFM4ENT PEFAMT ORNEWAYAX(MM) <br />