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1. <br />THE APPLICANT HEREBY CERTIFIES: <br />Thathe/she has read all the'provisionsof this application,and that the description includedinthis application are correct to the best ofhislherknowledge;and ,, <br />2.That he/she isthe ownerof the respectiveproperty,or Isgualltied to representtheowner;and <br />3.That he/shewill assume full responsibilityfor all liabilityfor persona;injuryor damageto property which may ariseoul of the workdescribedabove,or which mayarise'out of his/herfailureto do the work providedherein;and ,. <br />4.That in the event any ciaim of such liabilityis made againstthe County of San Joaquin or any department,official or employeethereof,he sh~1Ide(end,indemnify andhold them and eachof them harmiessfor such ciaim;and .'', <br />5.That wori(shall beperformed by the applicant and/orany representativeof the applicationin the County Right-of-Wayat the aboveindicatedsitewithavalidSanJoaquinCountyEncroachmentPermit;and <br />6.That if permission is granted as requested,he agreesto do the work descrtbedin accordanceiNithall terms,condition and restrictionofthisaanyattachedsheet,inciudedasgeneral or spe,ciailll provisions..'..,.' <br />bfh1l t{(z It '. <br />Signature of Applicant Title Date <br />»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FIELD INSPECTIONCOMMENTS««««««««««««««««««<<<<<<<EXISTINGCONDITIONS <br />'1, <br />1.DRIVEWAY:Non~J2'I Dirt 0 Gravel 0 Aggregate Base 0 Paved (poor)0 Pav~d(good)0 <br />2.SLOPING:Away from Pavement IZf Towards Pavement 0 Flat 0 <br />3.PIPES:None JZI Existing-Type._ <br />Other pipes in neighborhood:Yes 0 No 0 Approaches 0 Cross Drain 0 Size _ <br />4.HEADWALL:Yes 0 No JZf <br />5.ASPHALT CONCRETE DiKE:,Yes 0 No 0' <br />6.BARRIERS:.along Right-of-Way _ <br />7.DITCH:Yes 0 No IZIlfYes:V Style 0 2 Point 0 Other 0 Width Depth..... <br />»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>PERMITS REQUIREMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />1.DRIVEWAY:SFR [J Commercial 0 Agricuiture 0 Industrial 0 <br />Paved with ._'Min DepthAC.over ..."Min Depth%'AB.over <br />Notes: <br />2.PIPES: <br />Notes: <br />Length of Pipe Required Ft.and Diameter of Pipe inch(es) <br />To beconnected to any adjacent driveway pipe Yes 0 No 0 <br />Drainage Inlet Required Yes 0 No 0 <br />Total Length:'(with proposed)Total Number of StormDrain Inlets:_ <br />3.HEADWALL:Yes 0 No 0 <br />4.PAVED FRONTAGE:Paved with ."Min Depth A.C.over "Min Depth %"AB. <br />Measuring Feet in length and F.eetin width <br />»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FEES«««««««««««<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />Drtveway Encroachment Permit base fee,_~_$135.00 <br />Field Ins ectionDrivewayw/or w/o pipe,$.121.00 <br />Driveway w/box Culvert_.....__.$181.00 <br />M:\CENTRAlSERVlCESlCLERlCAl\PllB-SV,WKIMASTERPSlENCROACHMENT PERMITDRIIJE1NA V,DOC (09113) <br />B Paved Frontage $116.00 +0.53/ft.Curb,Gutter,Sidewalk $121.00 +1.16/ft. <br />Palle2of2