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T <br /> TRE APPUCAN T HEREBY C RTFIES: <br /> 1. That he/she has read all the provisions of this application,and that the included in this application are oorrt to the best <br /> his/her knowledge:and of <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 dePaftent,official or empk e <br /> thereof,he shalt defend,indemnify and hold them and each of them harmless ibr such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the appy in County Riot-o ay at <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 fest <br /> of this and any attached sheet.included as general or special III provisions. <br /> thoe+ti tJ7 t.�wrr h�2 Inc T <br /> L rrat INE 5/-2,7 /10 <br /> Signature of Applicant 1 its ate <br /> >»»»»»»»»»»»»»»»»»»»»»FIELD INSPECTION COMA 'S«««««««<<<<<<««<<«,t«<<<r««<<.O<.< <br /> MSTING CONDffbM § <br /> 1. DRIVEWAY: None ❑ Dirt 0Gravel C Aggregate Base © Paved(poor) 17 Paved(good) <br /> 2. SLOPING: Away from pavement 71 Towards Pavement Flat <br /> 3. PIPES: none lI Existing Type <br /> Other pipes in neighborhood: Yes l�O Approaches Gross Drain Size <br /> 4. HEADVIALL: Yes U No <br /> 5. ASPHALT CONCRETE DIKE: Yes 1=1 No YK <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes 7, No if Yes; V Styie F-1 2 Point l7 Other ❑ Width Depth <br /> »»»»>»»»>»»»»»»»»»»»»»»»»PERMITS REGI WXM TS««ce«««««c«««<c«««c«««�c+c<< <br /> 1. DRIVEWAY: SFR f 1# Commercial jr Agriculture F71 Industrial <br /> Paved with "Min Depth A.C.over "{din Depth'/"A.B.over <br /> Notes: <br /> 2, PIPES: Length of Pipe Required J/A Ft,and Diameter of Pipe inches} <br /> To be connected to any adjacent driveway pipe Yes F-1 No. <br /> Drainage inlet Required Yes 0 No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes 7 No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth'J"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«<«.,,s 4e<-<«««««<«<<<«««««««««««<<< <br /> ,Driveway Encroachment Permit base fee 17-5-. °° a <br /> Field in <br /> ellen <br /> �C Z Driveway w/or w/o Pipe l!0'Q-0 < 4pa-urb, <br /> e i 13.QfI+4.52!#t <br /> a Driveway w/box Culvert 3175.00 dewalks $110.00 t 1.051ft. <br /> W":CE+`d'�Sv.ScRWICE5'GLER'.CAr'OSB-S'J:JJK'Sr1A.S'?Er�.pS1EYCF2'JA::f4A .0.T? ESP��ENIFlY.v+�C (tGfGB Pac*20t2 <br />