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THE APPLICANT HEREBY CERTIFIES: <br />1.That he/she has read all the provisions of this application,and Ihat the description included in this application are correct to the besl ofhislherknowledge:and <br />2.That he/she 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 workdescribedabove,or which may arise out of his/her failure to do the work provided herein;and <br />4.That in the event any claim of such liability is made against the County of San Joaquin or any department,official or employeethereof,he shall defend,indemnify and hold them and each of them hanmless for such claim:and <br />5.That work shall be perfonmed by the applicant and/or any representative of the application in the County Right-of-Way at the aboveindicatedsitewithavalidSanJoaquinCountyEncroachmentPenmit;and <br />6.That if penmission is granted as requested,he agrees to do Ihe work described in accordance with all terms,condition and restriction <br />of this a7/0:;:edsh ,.cl!&ed as general or special III provisions.3h a Up <br />.Signature of Applicant Title ~Date <br />»»»»»»»»»»»»»»»»»»»»»>FIE LDINSPECTIONCOMMENTS«««««««««««««««««««««< <br />EXISTING CONDITIONS <br />No [;£ <br />NoneA Dirt 0 Gravel 0 Aggregate Base 0 Paved (poor)0 Paved (good)0 <br />Away from Pavement rtl Towards Pavement 0 Flat 0 <br />None ill Existing -Type Ji..,""-_~~_~~~_Olher pipes in neighborhood:Yes kJ No 0 Approaches if{Cross Drain 0 Size _ <br />NO~ <br />1.DRIVEWAY: <br />2.SLOPING: <br />3.PIPES: <br />4.HEADWALL:Yes 0 <br />5.ASPHALT CONCRETE DIKE:Yes 0 <br />6.BARRIERS:along Right-of-Way ~~----~--_ <br />7.DITCH:Yes,!1 No 0 If Yes:V Style 0 2 Point 0 Other 0 Width __C_l'_Depth--.!f- <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMITSREQUIREMENTS««««««««««««««««««««« <br />1.DRIVEWAY:SFrt;JJJJ Commercial 0 A9riCulture~Industrial 0 <br />Paved with 2--"Min Depth A.C.over 0 "Min Depth 7\"A.B.over <br />Notes: <br />2.PIPES:Length of Pipe Required Fl.and Diameler of Pipe Z 1-.inch(es)--------L£'L><..G;bl..<it II.<.)G-t~,."'4JC.ce..<-fTobeconnectedtoanyadjacentdrivewaypipeYyeeSsDONNoo'p-r"&r+'1 -t.oft-....oc'$f •.Drainage Inlet Required r- <br />Total Length:(with proposed)Total Number of Storm Drain Inlets:_ <br />Notes: <br />3.HEADWALL:Yes 0 No ~ <br />4.PAVED FRONTAGE:Paved with "Min Depth A.C.over "Min Depth 7\"A.B. <br />Measuring Feet in length and Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway Encroachment Penmit base fee $85.00 <br />Field Ins ectionDrivewayw/or w/o pipec ~S95.00DrivewaywlboxCulvertS155.00 <br />MICENTRAlSERVlCES\CLERlCAl'f>UB-SVWl<IMASTERPSIENCROACHMENT PERM TDRlVEWAV.DOC (01.oa) <br />EJ Paved Frontage S100.00 t OA6/ft. <br />Curb,Guller,Sidewalk $100.00 t 0.98/ft. <br />Page 2 of2