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THE APPLICANT HEREBY CERTIFIES: <br />5. <br />4. <br />3. <br />2. <br />•-, <br />1. <br />6. <br />That he/slle has read all the'provisionsof this'application,and that the description included in this application are correct to the best ofhis/her knowledge;and <br />Thathelshe is the owner of the respectiveproperty,or isqUalifiedto represent the owner;and <br />That helshe will assume fuli responsibilityfor all liabilityfor persona;injury or damage to property which mayanse out of the warl(described above,or which may arise'out of hislher failureto do the worl(provided herein;and <br />That in theevent any claim of such liabilityis made againstthe County of San Joaquin or any department,official or employeethereof,he shall defend,indemnify andhold them and eachof them harmless for such claim;and . <br />That work shall be performed by the applicant and/or any representativeof the application in the County Right-of-Way at the~aboveindicatedsitewithavalidSanJoaquinCountyEncroachm.enjPermit;and •. <br />That if penmissionis granted as requested,he agreesto do the work described in accordance with all terms,condition and restrictionofthisandanyattachedsheet,inciuded asgenerai or spe.cialiii provisions,.K .~,.D5"'..:lfa -/(,'.Signature of Applicant Tltie ate <br />»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FIELDINSPECTIONCOl\llr,,;;NTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<EXISTINGCONDITIONS. <br />1.DRIVEWAY:None 0 Dirt 0 Gravel M.Aggre~~te Base 0 Paved (poor)0 Paved (good)0 <br />2.SLOPIi,G:Away from Pavement 0 Towards Pavement 0 Flat <br />3.PiPES:None&EXisting-Type'\Z"'CM.P fA~.'_.. <br />Other pipes in neighborhood:Yes No Approaches ~Cross Drain U Size _ <br />4.HEADWALL:Yes 0 No rl- <br />5.ASPHALT CONCRETE DIKE:.Yes 0 No a. <br />6.BARRiERS:along Right-of-Way _ <br />7.DITCH:Yesl9-No ~lfYes:V Style 0 2 Point 0 Other 0 Width Depth------- <br />»»»»»»»»»»»»»»»>>>>>>>>>>>>>>>>>>PERMITS REQUIREI\IIENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />1.DRIVEWAY:SFR q Commercial Ji!f Agriculture 0 Industrial 0 <br />Paved with "2-"Min Depth A.G.over Go?"Min Depth %'A.B.over <br />Notes: <br />----o----------------,~.,......~_~/,z.j)jrI). <br />2.PIPES:Length of Pipe Required FlandDiameterofPipe J:t"(JL.;J inch(es) <br />To be connected to any adjacent driveway pipe Yes 0 No l!:I <br />Drainage Inlet Required Yes 0 No iia <br />Total Length:.(with proposed)Total Number of StonmDrain Inlets:------ <br />Jotes: <br />.HEADWALL:Yes 0 No 0 <br />.PAVED FRONTAGE:Paved with "Min Depth A.C.over "Min Depth W A.B. <br />Measuring Feet in length and Feet in width <br />»»»>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FEES«««««««««««<<<<<<<<<<<<<<<<«««<<<<<<<<<< <br />rivaway Encroachment Permit base fee $135.00 <br />eld Inspection <br />Driveway wi or wlo pipe $121.00DrivewaywiboxCulvert$181.00------ <br />~ENTRAlSERVJCES\ClER1CAl\PUB.SV.WK\MASTER.PSlENCROACHMENT PERMIT DRIVEWAY.DOC (09J1J) <br />B Paved Frontage $116.00 +0.53/ftCurb,Gutter,Sid~e-w~alk----$121.00 +1.16/ft.---Paoe211f?