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THE APPLICANT HEREBY CERTIFIES: <br />1,That helshe has read allthe'provisionsof this application,and that the descriptionincludedin this applicationarecorrect to the best ofhislherknowledge;and . <br />2,That helshe is the ownerof the respectivepropeliy,or is gualified to representth~owner;and <br />3,That helshe will assumefull responsibilityfor all liabilityfor persona;injury or damageto property which may arise out of the workdescribedabove,or which may arise'outof his/herfailure to do the workprovidedherein;and <br />4,That in the eventany claimof such liabilityis madeagainstthe County of San Joaquinor any department,official or employeethereof,he sh911 defend,indemnifyand hold them and each of them harmlessfor such claim;and <br />5,That work shall be performedbythe applicantand/orany representativeof the applicationin the CountyRigh!-of-Wayat the above <br />indicatedsite with a valid SanJoaquinCountyEncroachm,entPermit;and , <br />6,That if permission isgranted as requested,he agreesto do the work describedin accordancewith all terms,condition and restriction' <br />of this and anyaffached~heet,includedas ~eneral or special \II provisions./'' <br />i /;$'-"'8;L!'I~i ate' <br />»»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FIELD INSPECTIONCOMMENTS««««<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<EXISTINGCONDITIONS <br />" <br />1.DRIVEWAY:None D Dirt~Gravel D Aggreg~teBase D Paved(poor)D Paved (good)D <br />2.SLOPING:Away from Pavement D TowardsPavement D Fla~- <br />3.PIPES:NoneM Existing-Type~~'__~~_~~~~ <br />OtherPifjes in neighborhood:Yes 0 No 0 Approaches 0 Cross Drain 0 Size_'~~~_ <br />4.HEADWALL:Yes D No ~ <br />5.ASPHALT CONCRETEDIKE:,Yes D NoJi;[, <br />6.BARRIERS:along Right-of-Way ~~~~_ <br />7.DITCH:Yes D No A!If Yes:V Style D 2 Point D Other D Width Depth _ <br />»»»»»»»»»»»»»»»»»»»»»»»»PERMtTSREQUIREMENTS««««««««««««««««««««<< <br />1.DRIVEWAY:SFRAf Commercial 0 Agriculture 0 Industrial D <br />Paved with 2."Min Depth A.C.over 4 "Min Depth%"A.B,over <br />Notes: <br />" <br />inch(es)2.PIPES: <br />Notes: <br />Length of Pipe Required <br />To be connected to any adjacent drIVewaypipe Yes D <br />Drainage InletRequired Yes D <br />Total Length:'(with proposed) <br />Ft.and Diameter of Pipe <br />~~~",. <br />Total Numberof Storm Drain Inlels:~_ <br />3.HEADWALL:Yes 0 No ~ <br />4.PAVED FRONTAGE:Paved with "Min DepthA.C.over "Min Depth %"AB. <br />Measuring _~~~~_Feetin lengthand Feet in width <br />»»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br />Driveway EncroachmentPermit base fee $135,00 <br />Field InspectionDrivewaywi or wlo pipe~$121.00DrivewaywlboxCulvert~$181.00 <br />''.It''l::,rro.r C'='nr'<:Clf'1<:o01f"1 lOlI0.C,IJ"'If1"A"=t:I "Cc\~.T"'''''M''LJ''~.TTD~DUlT"CnJQor~vnnl""IM!1~\ <br />B Paved Frontage '$116.00+0.53/ft.Curb,Gutter,Sidewalk $,121.00+1.16/ft. <br />"~n~1nl1