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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 /> hisfiter knowledge;and <br /> 2. That helshe is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That helshe will assurnefull responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> desaibed.,abow,or wtrich may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such Iia#ty is made against the County of San Joaquin or any department,official or employee <br /> thereat he shall defend,indemify 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 vafid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,be agrees to do the work described in accordance with all terms,condition and restriction <br /> of this sheat,' as gen special III provisions. <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»>FIELD INSPECTION C011 MENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None;❑ Dirt Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ff"Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None [Existing—Type <br /> Other pipes in rrborhood: Yes No Approaches Ll Cross Drain LJ Size <br /> 4. HEADWALL: Yes ❑ Noy. <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along,Right-of-Way s <br /> iie <br /> 7. DITCH: Yes ❑ No Yes: V Style 0 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br /> rt � <br /> Paved with 2 "Min Depth A.C.over "Min Depth Y4"AB.over <br /> 2. PIPES: Length of Pipe Required <br /> 1A Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [ `� <br /> Drainage Inlet Required Yes ❑ No ER" <br /> Total Length: '"" (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [+ <br /> 4. PAVED FRONTAGE: Paved with ,�i "Min Depth A.C.over "Min Depth Y4"A.B. <br /> Measuring Feet in length and Feet in width <br /> f <br /> { <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee <br /> $125:00iield c <br /> 23�' <br /> Insoection <br /> riveway w/or wlo pipe $110.00 H <br /> Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> kWPWGOV.ORG1SWESICEN RAI.SERVICEMER1CAl1Pt1B,W.WKUuIASTER.PSIENCROACHMENT PERMIT DRNEWAY.DOC (10109) Page 2 of 2 <br />