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1. That helshe has read all the provisions of this application,and that the description included in this appocaticra are correct th the best of � <br /> hi&%r knowledge;and <br /> 2. That helshe 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 shall defend,indemnify and hold them and each of them harmfess for such claim;and <br /> 5. That work shall be performed by the applicant andlor any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid Sara 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 teras,c oncriitior and resirictio <br /> of this and any attached sheet,included as genera or special III provisions. <br /> Signature of Aeptft Tile Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIEL I)HWECTMNr CEJMMENTSc««««««««««««««««««««« <br /> EYJSTM CON 3IT 646 <br /> 1. DRIVEWAY: gone ❑ Dirt Y"eGravel Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement Towards Pavement ❑ Flat <br /> 3. PIPES: None [ E Existing—Type ° <br /> Other pipes in neighbofiood: Yes No Approaches Cross Drain Site <br /> 4. HEADWALL: Yes ❑ No [ ` <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No . <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No es: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PEf MITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SPR ❑ Commercial [ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth,Y4"AB.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required '` "' Ft.and Diameter of Pipe inches) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet RequiredYes F1No <br /> Total Length: .,.£- (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [ <br /> 4. PAVED FRONTAGE: Paved with n' "Min Depth A.C.over "Min Depth Y4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«««««««««««««««««««««<a«<4««« <br /> Driveway Encroachment Permit base fee_$125.00 <br /> 7, <br /> i Ins .on <br /> Ahl Driveway w/or wlo pipe $110.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 ❑ Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> 11SIPWGOV.ORG&ME=ENTRALSSWCESICLERICALIPUB-SV.WKWASTER.PMKROACMMENTTPERNNTDRNEWAY.DOC (10109) Page2of2 <br />