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1. That he/she has read all the provisions of thisn, y <br /> his/her knowledge;andPk are00110di6th0b", <br /> 2. That he/she is the owner of the respective prey,or is qua d tor*xesent. e <br /> aw <br /> 3. That he/she will assume full responsibility for all liability for persona; or damage tO.pfOp"whichMW atise out of the work <br /> described above,or which may arise out of his/her%lure to do the work ad <br /> 4. That in the event any claim of such liability is made against the County of S <br /> da:W or employee <br /> thereof,he shall defend,indemnify and, thein and each of art hn tt ' <br /> 5. That work shall be performed by the applicant and/or any re err"of the oppficatlon th ft Owy RW,Way at <br /> indicated site with a valid San Joaquin County Encroachn Peffnk'and the abo% <br /> 6. That if permission is granted as requested,he fees to do the work iia �with ,WM, reakkaw <br /> of this and any attach she included as or sperm 111 pmv . <br /> Signature of Apicant Tile _ <br /> »»»»»»»>»»»»»»»»»»»»>>>>F EW SP CTIO'N ColpgtV <br /> 1. DRIVEWAY: None 121 Dirt ❑ Gravel ❑ AggregateBase ❑ Paved ) ❑ Paver Lgood) ❑ <br /> 2. SLOPING:" N Away from Pavement R"'Towards Pavement ❑ Flat n <br /> 3. PIPES: None a-"Existing-Type <br /> Other pipes in neighborhood: Yes N0, Approaches U Cross i , <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ ' <br /> 6. BARRIERS: along Right-of-Way J6?r <br /> 7. DITCH: Yes [ ""No ❑ If Yes: V <br /> Style ❑ 2 Point ❑ Other ❑ Wit <br /> Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PEfi WS REOUMMl «««<<<<<<««««<<�k<«««C««<«« <br /> 1. DRIVEWAY: SFR ❑ Commercial 2' Agriculture ❑ Industrial <br /> Paved with <br /> "Min Depth A.C.over "Mht Depth V7 A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required —ice Ft and Diameter of Pipe irrch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [ <br /> Drainage Inlet Required Yes ❑ Na <br /> Total Length: (with proposed) Tom Number of Storer Drain Its <br /> Notes: .qle W <br /> J <br /> 3. HEADWALL: Yes ❑ No [ <br /> 4. PAVED FRONTAGE: Paved with A_. <br /> "Min Depth A.C.over "WM Dearth V AB. <br /> Measuring Feet in length and ---__Feet thwidth <br /> , <br /> »»»»>»»»»»»»»»»>»»»»»»»»»»»»FEES««««««««««««««««««<««««««ac«« <br /> Driveway Encroachment Permit base fee f $125.00 <br /> M <br /> ld Ins ection - <br /> Driveway w/or w/o pipe_ ( $110.00 Paved Frontage $116.00+0.53ftf. <br /> Driveway w/box Culvert $179.00 ❑ Curb,Gomer, walk <$113.00+1.( t <br /> tWPWGOVORGISHARESICENRAISERVICEMLERICALPU&SV.WKwASTER:PSIENCROACWMPSWDRNEMyDoC (IM PV202 <br />