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THE APPUC.ANt HEREFf CERTOES: <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> his1E 'knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> described above,or which may arise out of his/her failure to do the work provided herein:and <br /> 4. That in the event any claim of such liability is made against the County of San Joaquin or any department,official or employee <br /> thereof;he shalt defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of th` any ed sheet,included as general or special III provisions. <br /> ?._Doi <br /> Signature if Applicant Title —mate <br /> I>A»»»»»»»»»>>>>>i»> >NI-JO>,»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) [ " <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement [2"' Flat ❑ <br /> 3. PIPES: None ge Existing–Type <br /> Other pipes in neighborhood: Yes LJ No Approaches Cross Drain I I Size <br /> 4. HEADWALL: Yes ❑ No [ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ <br /> 6. BARRIERS: along night-of-Way .f <br /> 7. DITCH Yes ❑ No R'If Yes; V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»>»»»»»»»»»»>»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial �`` Agriculture ❑ Industrial ❑ <br /> �,� <br /> Paved with "Min Depth A.C.over (. ' "Min Depth'/4"A.B.over <br /> Notes.: .� <br /> yeti.. <br /> t <br /> :','� ���� Ft.and Diameter of Pie inch(es) <br /> 2. PIPES: Length of Pipe Required p <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 /> rye *' r r W� Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»> »»»»»>FEES««««««««««<<<<< ««««««««««« <br /> 66 <br /> Driveway Encroachment Permit base fee 100.0 0 101, <br /> 1 / <br /> y" r <br /> Field Inspection <br /> Driveway w/or w/o pipe $1 7. ❑ Paved Frontage $113.00+0.52/ft. <br /> Driveway w/box Culvert 7 Curb.Gutter,Sidewalk $110.00+1.05/ft. <br /> Nt10ENTRALSERVICESZLERKAL4PU&SV.WKiMASTER.PMENCROACHMENT PERMIT DRIVE)NAY.DOC (10109) Page 2 of 2 <br />