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THE APPLICANT HEREBY-CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that th*desmon inc ed in this ap ation are correct to the best of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to rem the tomer,and <br /> 3. That he/she will assume full responsibility for all liability for persona;hjuty or carnage to properly whim may arise out of the work <br /> described above,or which may arise out of his/her failure to do the wt #coovided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San ` or any departnieK or emobyes <br /> thereof,he shah defend,indemnify and hold them and each of'temhhrr ,ss first ;am <br /> 5. That work shall be performed by the applicant andlor any represent of the appt r y y the aborr } <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is grants as,eques ,fie agrees to do the work described in accordance with all teras, n and reser <br /> of this and any hed est,incl as general or special Ill provisions: <br /> / - -a <br /> ignature of Applicant Title owe <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMM€Il 7S<<«««{««««<C««««c«««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel El' Aggregate Base ❑ Paved(poor) ❑ Parted*4 [ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drn Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No ✓Q <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No Q If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Doh <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQfJIR ENM<<<«««««r««««««««««««<«� <br /> 1. DRIVEWAY: SFR [g' Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Deft W A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe int ries) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over °Min Depth "A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«<<<<<<«««c««<cc«««««<r««««<t«« <br /> Driveway Encroachment Permit base fee $90.00 <br /> Field Ins ection <br /> Driveway w/or w/o pipe $102.00 Paved Frontaggee $108.00+0.WM. <br /> Driveway w/box Culvert $167.00 ❑ Curb,Cutter,S dewalk $105.00+I.0n. <br /> Y.MRMS&TEW ATES1ENCROAM ENT PERMIT DRIVEWAY.doe(OWW <br />