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P - gY G�TI�fES: <br /> t t>aa(gid aN tfte provisions of this application,and that the description included in this application are correct to the best of <br /> ar�d <br /> 2. -fit is theorof the respective property,or is qualified to represent the owner;and <br /> txne U1 responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> 3' a �r-may arse out of his/her failure to do the work provided herein;and <br /> � . <br /> 4.' ��tha ; ydaim of such liability is made against the County rom Saness forasuch clai;anuin or any dadment,official or employee <br /> thlowf , emnify and hold them and each of them <br /> 5. <br /> . � by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> a vat San Joaquin County.Encroachment Permit;an <br /> 6. granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> tf y Wit,included as general or special III provisions. <br /> ate <br /> tore of Applicant Title <br /> > > > »>y> a>y»yy»»»»»>FIELD INSPECTIONNG CONDITIONSCOMENTS«««««««««««««««««««««< <br /> EXISTI <br /> t. <br /> MAY: None- ❑ Dkt [ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2 SSG: Awq from Pavement ❑ Towards Pavement Flat ❑ <br /> � � . —Tywd. Yes No Approaches Cross Drain Size__ <br /> 4. WzAVWALL Yes ❑ No <br /> S. ASM&T O ETE DIKE: Yes ❑, No <br /> 6. BAFFAERS: akxV IW-d-Way <br /> " No if Yes: V Style ❑ 2 Point F1 Other ❑ Width Depth <br /> 7: '�: Yep ❑ <br /> > � >>>>>>»»>y»»»a»»»»»»>PERMITS REQUIREMENTS««<<<<< ««««««««««««« <br /> SIrR <br /> Cornmerdal f-1 Agriculture [I Industrial ❑ <br /> SFA "Min Depth A.C.over "Min Depth 3/4"A.B.over <br /> Pis: <br /> Of Pipe Required Ft.and Diameter of Pipe <br /> inch(es) <br /> 2. PIPES: <br /> To be txonr> ed to any adjacent driveway pipe Yes F1 No <br /> Yes C] No <br /> Drage Inlet Required Total Number of Storm Drain Inlets: <br /> 1. Lam: (with proposed) <br /> NOW. <br /> 3 KADWALL: Yes ❑ No <br /> "Min Depth A.C.over_____________ "Min Depth 3/4'A.B. <br /> 4. PAVED F� Paved Feet in length and Feet in width <br /> Measuring <br /> »may>>>»»»»»>>»»»>»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> DriveNay Enavg*y"t Perrnit base fee $90.00 <br /> Paved Frontage $108.00+0.50/ft. <br /> Vd or w10 _$102.00 ❑ Curb,Gutter,Sidewalk______$105.00+1.031ft. <br /> fly w box Culuert $167.00 <br /> Y;*006 11 TOM dt'M"9"*A0AVa WAGWAY.d"c(W" <br />