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TLJG nnnr rnANITHEREBYC`ERTIFIES: <br /> nrrLIVnry r r 11-1rL-u r L ` <br /> 1. That he/she has read all the provisions of this appkafi n,.; f � e correct to the best of <br /> his/her knowledge;and <br /> 2• That he/she is the owner of the respective property,or is qtW&d toW ft oar; <br /> and <br /> 3. That he/she will assume full responsibility for all liability for persona;injury o ' <br /> described above,or which may arise out ofhis/her(allure to do,the�provided he ein, which nvy arise out of the work <br /> 4. That in the event any claim of such liability is made agair>st the Coup of San JOaqulili or <br /> thereof,he shall defend,indemnify and hold theft and each of mei ,r , eiil, or employee <br /> 5. That work shall be performed by the applicant antt/tir any representative of the a Right-of-Way at the above <br /> site with a valid San Joaquin County Encroachment brit;, <br /> and6. That if permission is granted as requested,he agrees to do the work desmbed in acctDPftA0e WM a#10MIS,condition and restriction <br /> of this andfeny attached sheet, ' cluded as neral or special III provi km. <br /> Signature Ap n <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD WW-SK-C' <br /> 1. DRIVEWAY: None [] Dirt ❑ Gravel ❑ Aggregate Base ❑ Payed `i' Pam(6 04 <br /> 2. SLOPING: Away from Pavement FkJ" Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ❑" Existing-Type A11,14' <br /> Other pipes in neighborhood: YesNo >p#x`o d row hl S'rle <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [► ° <br /> 6. BARRIERS: along Right-of-Way idoee. <br /> 7. DITCH: Yes ❑ No [ ff Yes: V Style ❑ 2 Point ❑ Other ❑ WXM peps <br /> »»»»»»»»»»»»»»»»»»»»»»>>>>M.MTS RECARREMENTS««««««e««««z«««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial 03"-Agriculture ❑ Industrial ❑ <br /> Paved with y "Min Depth A.C.over "lin Depth Ve A,B.Over <br /> Notes <br /> 2. PIPES: Length of Pipe Required ' Ft and Diameter of Pipe ". <br /> 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 /> Notes.- <br /> 3. <br /> otes3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with ,E. "Min Depth A,C.over "Min Depth 3A"A.B. <br /> Pleasuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««c«<««««<<«««c«««<<««««««««< <br /> Driveway Encroachment Permit base fee $90.00 <br /> Field inspection <br /> Driveway w/or w/o pipe $102.00 Paved Frontage $108.00+0,50/ff. <br /> Driveway w/box Culvert $167.00 Curb,Gutter, ewal $105,00+I,GNft. <br /> Y'IFORMS 8 TEWP{ATES'ENCROACHANT PEROT CRWE`NAY dca ftWi <br />