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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 /> hiskw knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That hem 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 SCh may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such Wity 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 harmless for such claim;and <br /> 5. That work shah be{mimed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if perms .valted as rte,he agrees to work described in accordance with all terms,condition and restriction <br /> of,th' a��ed fi,ir�clud i as g; n al III provisions. <br /> Signature of Apphmt Title �—�-T ate <br /> »»»»»»»»»»»»>>»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ff"Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement [Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: Noce f-1EA -Type ! r % 1J,a <br /> Cther'pipes in . Yes 'No LJ Approaches LJ Cross Drain LJ Size r - <br /> t <br /> 4. HEADWALL: Yes ❑ No µ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No Ef <br /> , <br /> 6. BARRIERS along"Riga-of:Way A10A " <br /> 7. DITCH: Yes [1"No ❑ 1f Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑, Agriculture ❑ Industrial ❑ <br /> Paved with f "Min Depth A.C.over "Min Depth%"A.B.over <br /> Notes: <br /> i <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe '" inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No a <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [ <br /> i/ <br /> 4. PAVED FRONTAGE: Paved withMin Depth A.C.over "Min Depth'/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> >>>»»»»>>»»»»»»»»»»>»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Inspection 235 <br /> Driveway w/or w/o pipe $110.00 Paved Frontage $116.00+0.53/ft. <br /> JI'Driveway wtbox Culvert. $179.00 ❑ Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> I%pWGOV.ORGXSWE RICALTM-SV.WKWULSTER.PS1EPlCROACHM£NT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br />