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r <br /> 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 /> histher 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 he/she will assume full responsibility for all liability for persona;k*x y 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,Acial or employee <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant angor any representative of the application in the County Right—of—Way at tfte above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested, <br /> he.agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and any�ed t,i ded as geror special Ill provisions. <br /> Signature of / <br /> ig Applicant Title <br /> »»»»»>»»»»»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None [ ° Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) <br /> 2. SLOPING: olway from Pavement 0'..Towards Pavement ❑ Fiat <br /> 3. PIPES: None [ij"' Existing—Type <br /> Other pipes-in neighborhood: Yes No Lff"Approaches LJ Cross Drain U Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ <br /> 6. BARRIERS: along Right-0f-Way <br /> 7. DITCH: Yes ❑ No [�, Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»»»»»>»»»»»>>»»»»»»»PERMITS REQWRE ITS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over ! "Min Depth VV A.B.over <br /> Notes: a� �....." <br /> 2. PIPES: Len Required " <br /> Length of Pipe p eq Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No [3-'w-- <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: A. <br /> Notes: <br /> i <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth f<"A.B. <br /> Measuring Feet in length andFeet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Ins ction <br /> Driveway w/or w/o pipe <br /> _$I 10.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 ❑ Curb,Gutter,Sidewalk $113.00+1.08/ft <br /> OSJPWGOV.ORGZWESICENTRALSERVICESICLERICALtPU&SV.WKUAASTER.PSIENCROACFUENTPERMITDRIVEWAY.DOC (IM Page 2of2 <br />