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THE APPLICANT HEREBY CERTIFIES: <br /> 1 TW hefshe,has read aIi the provisions of this application,and that the description included in this appiication are correct to the best of <br /> his ser ,and <br /> 2. That hefshe is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> desorbecl above,or which may arise out of his/her failure to do the work provided herein;and <br /> 4_ That in the eves:any claim of such liability is made against the County of San Joaquin or any department,official or employee <br /> he shall,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall bre performed by the applicant antUor any representative of the application in the County Right-of-Way at the above <br /> ' <br /> in site w a vakcf San Joaquin County Encroachment Permit;and <br /> g. That if permission is granted as requested,he appees to do the work described in accordance with all terms,condition and restriction <br /> of this and a 4e inch as Z rat or.special III provisions. <br /> r e pitcant Tin <br /> »»»»»>>>,»»»»»»»»»»»»»»»FtELO INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> i DRIVEWAY: Norte ❑ Dirtk Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from pavement'o Towards Pavement ❑ Flat <br /> 3. PIPES: NoneExisting-Type roaches Cross Drain Size <br /> - <br /> 4. <br /> to neighborhood: Yes No App <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE. Yes ❑ No <br /> 6. BARRIERS:. along Right-of-Way jd.► <br /> 7. DITCH: Yes ❑ No it Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»>,»,»»y»»»>>>>>>»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ industrial F-1Paved with + - "Min Depth A.C.over `7 "Min Depth 3/4'A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pie Required <br /> Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ N <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: .�' (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> "Min Depth 3/a"A.B. <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»>»»>»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $90.00 <br /> F1e1d110§pectiion $102.00 Paved Frontage $108.00+0.50/ft. <br /> Driveway w/or w/o pipe R Curb,Gutter,Sidewalk $105.00+1.03/ft. <br /> Driveway wlbox Culvert $167.00 <br /> ,TOAVS&TBW1ATE9ACfM ENT AEFUT OPoVEWAVAM(06/08) <br />