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1. That he/she has read all the provisions of this application,and that the desc�i <br /> his/her knowledge;and on are mtect to the l <br /> 2. That he/she is the owner of the respective property,or is qualftd to represent the and <br /> 3. That he/she will assume full responsibility for all liability for persona;Injury or dmage to whiff <br /> described above,or which may arise out of his/her failure to do the work I terse out of(he work <br /> herein;and <br /> 4. That in the event any claim of such liability is made against the Cou of San Joaqw or any deparb,"00 <br /> thereof,he shall defend,indemnify and hold them and each of tI m harmless <br /> 5. That work shall beerformed b the <br /> P y applicant and/or any represenwve of thee.Avilicatimin the, <br /> : <br /> indicated site with a valid San Joaquin County Encroachment Pere*and <br /> 6. That if permission is granted as requested,he agrees to do the work described in ice whha# <br /> of this and any a c hed sheet,in ed as general or special III <br /> Vis. <br /> Sign ture of pliant Title <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD WSPECTION COMAEWS««<t««« ««<c«««<« «<c« «< <br /> EXIMNG CQIDt'i`lt s <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) [ P t <br /> {gam) ❑ I <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None [Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No [c. <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> lor, i <br /> 7. DITCH: Yes ❑ No ER'If Yes: V Style ❑ Mint ❑ Other ❑ W'Kfh peps <br /> »»»»»>»»»»»»»»»»»»»»»»»»>PERMITS REQUIREMEWS<<<<<<<<<<<<<<<<'<<<<'c<<<,<<<<<4<<<<<<<<< <br /> << «««««<<'c« «« t«ts tc< <br /> 1. DRIVEWAY: SFR [ `Commercial ❑ Agriculture ❑ Industrial ❑: <br /> Paved with "Min Depth A.C.over 7 'Min Depth Y.'A.B.over <br /> Notes: <br /> i <br /> 2. PIPES: Length of Pipe Required1411 <br /> . ) <br /> Ft.and Diameter of Pipe <br /> To be connected to any adjacent driveway pipe Yes ❑ No I <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: "" (with proposed) Total Number of Storm Drain inlets: <br /> i <br /> Notes: <br /> i <br /> 3. HEADWALL: Yes ❑ No [g- <br /> 4. PAVED FRONTAGE: Paved with ` ` "Min Depth A.C.over Min kB. <br /> Measuring Feet in length and Feet 3 " <br /> ..,E <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«««««««««««««««««««< ««<c««« < <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field InsDecfion <br /> Driveway w/or w/o pipe $110.00 paved Fron <br /> Driveway w/box Culvert $179.00 $116.00+U.53�t. <br /> i <br /> Curb,Gutter,Sidewak $113.00+'l.O t. <br /> tWPWGOV.ORGISHARESICENTRALSERVICESICLERICALTUe-SV.WKWASTER.PSIENCROACHMENT PERM T DRIVEWAY.DOC {10" <br /> P2af2 <br /> i <br />