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THE APPLICANT HEREBY CERTIFIES: <br />1.ThaI he/she has read alilhe'provisionsof this application,and thaI the description included in Ihis application are correct to the best ofhislherknowiedge;and <br />2.That he/she is the owner of the respectiveproperty,or isgualified 10 represent theowner,and <br />3.That he/shewill assume full responsibilily for all liabilityfor persona;injury or damageto property which may arise out of the workdescribedabove,or which may arise'out of hisnlerfailure 10 do lile worll provided herein;and <br />4.Thatin theevent any claim of such liability is madeagainst the County of San Joaquin or any department,official or employeethereof,he shall de(end,indemnify and holdthem and each of them hanmlessfor such claim;and <br />5.That work shall be performed by tile applicant and/or any representative of the application in the County Right-of.Wayat the aboveindlcaledsilewithavalidSanJoaquinCountyEncroachmentPermit;and <br />6. <br />Signature of Applicant Title <br />Depth _ <br />Nodi <br />2.SLOPING: <br />3.PIPES: <br />»»»»»»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FIELDINSPECTIONCOMMENTS«<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<EXISTINGCONDITIONS <br />1.DRIVEWAY:NoneA Dirt 0 Gravel 0 Aggre~~le Base 0 Paved (poor)0 Paved (good)0 <br />Away from pavement!£f Towards Pavement 0 Fiat 0 - <br />NoneM Existing -Type~~~~~~~-,-4.<~1~~~~__~~~~~~~~Other~in neighborhood:Yes K£/No 0 Approaches ~Cross Drain 0 Size---..: <br />4.HEADWALL:Yes 0 No It? <br />5.ASPHALT CONCRETE DIKE:.Yes 0 <br />6.BARRIERS:along Right-of-Way ._._~~~~._ <br />7.DITCH:.Yes $i No 0 If Yes:V Style 0 2 Point 0 Other 0 Width _ <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITSREQUIREMENTS««««««««««««««««««««<< <br />1.DRIVEWAY:SFR 0 Commercial 0 Agriculture IKl Industrial 0 <br />Paved with ;2 'Mili Depth A.C.over ftz 'Min Depth%'A.B.over <br />Noles: <br />inch(es)113//Length of Pipe Required Fl and Diameter of Pipe <br />~~~.. <br />TotatE'ber of StonmDrain Inlets:_ <br />To be connected to any adjacent driveway pipe Yes 0 <br />Drainage Inlet Required Yes 0 <br />Tolal Length:.(with proposed) <br />2.PIPES: <br />Notes: <br />3.HEADWALL:Yes 0 No EL <br />4.PAVED FRONTAGE:Paved with 'Min Depth A.C.over _..•Min Depth %'A.B. <br />Measuring Feet in length and __..Feetlnwidth <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Permit base fee $135.00 <br />$121.00;,------~:181.00 B Paved Frontage $116.00 +0.531ft.Curb,Gutter,Sidewalk $121.00 +1.16/ft. <br />U-V:FNlllAf ~FRVlrFJ::Ir.IFRlr.A11P1 rR_'NWI(\~,IA_~p-~t:NN;>'lA('Ji!.AfNTPFWJJT 'lRI\~V l'V'V";:;.~ti~1 P:>n••',,"