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1. That hetshe°has read all the proovisior s of this application,and that the description included in this application are correct to the best of <br /> hLsdW knowledge;and <br /> 2. That hetshe is the ovtner of the respective property,or is qualified to represent the owner;and <br /> 3 Tl at vriti o full responst y for aH f ly for persona;injury or damage to property which may arise out of the work <br /> above,or which may arise eut of histher 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 /> #wW,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shalt be permed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indlcated,site w h a'vabd San Joaquin County Encroachment Permit;and <br /> 6. That if perrrssiorr ,grantedas nested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of#us ind any iftadw sh` ti►cud+ed as general or special[I]provisions. <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt [Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement flat ❑ <br /> 3. PIPES: Norte D�-1 dsting—Type <br /> Other pipes in n borh&A Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [�"_ <br /> 6. BARRIERS: along Right-of Way /-A o <br /> 7. DITCH: Yes❑ No if Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»>y»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR D�rComrnercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth%<"A.B.over <br /> ',d' ,h �J <br /> Notes: n tr%' ` �� <br /> All <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 [ <br /> Di-ainage Inlet Required Yes ❑ No <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 3/4"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Inspection <br /> Driveway w/or w/o pipe $110.00 H <br /> Paved Frontage $116.00+0.53Iff <br /> Driveway w/box Culvert $179.00 Curb,Gutter,Sidewalk $113.00+1.081ft. <br /> %W NIGM,M=1ARE$CENTRP1SfWCESCLERICAI of.SV.WKWASTER;Ps1ENGRQA(, AENT PERMR DRNEWAY.DOC (10109) Page 2 of 2 <br />