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THE APPUCAN T HEREBY CERT FES: <br /> 1. That he/she has read all the provisions of this application,and that the bion included in this ap$catiem WS=YWD focal of <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,oris 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 wank 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 empkyee <br /> thereof,he shall 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 ht 0 07�mare <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 mon <br /> of this and any attached sheet,included as ge ral or special III provisions, <br /> s b cc /G� <br /> Signature of Applicant Tide e <br /> »»»»>»»»»»»»»»»»»»»»»»FIELD INSPECTION COMMEWS«««««««««<««c<`c««<<<<.k< <,< <br /> EXISTINGCONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement [) Fiat ❑ <br /> 3. PIPES: None Z/Existing—Type <br /> Other pipes in neighborhood: Yes No Approves Cross Drain Sirze <br /> 4. HEADWALL: Yes ❑ No [ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way `l <br /> 7. DITCH: Yes ❑ No 2111f Yes: V Style ❑ 2 Point ❑ Other ❑ Width De <br /> pth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQIfIREMWS«««««<t««««««««<-<<<t««< << <br /> 1. DRIVEWAY: SFR [3 Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over ,a "Min Depth Y:`A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe inch(es) <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 5/4"A,B, <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»F EES««<<«««««««««««««««««««««<c«« <br /> Driveway Encroachment Permit base fee $100.00 apFeld Ins ection >Itzol. <br /> Driveway w/or w/o pipe $107.00 Paved Frontage $113.00+0.52/ft. <br /> ET Driveway w/box Culvert $175.00 8 Curb,Gutter,Sidewalk $110.00'+1,0&ft, <br /> M:ICENTRALSERVICES',CLERICAL`,PUB-SV.WKIMASTER.P&ENCROACHMENT PERMIT DRIVEWAY.DOC (10/09) Par202 <br />