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1. That he/she has read ail the provisions of this a i mfion,and that MAescription rrtdudecf in <br /> his/her know ge,and applicationthis are correct t to tfire best of <br /> 2. That hakhe is the owner of the respective property,or is died to represent the offer;and <br /> 3. That hese will assume full responsWity for all liability for persona;injury of image to try which may wise out of the work <br /> describedabove,or w ch may arise out of his/her faAn to do the work Fr ed ,and <br /> 4. That in the event any claim of such batt is made against the County of San Joaquin or any department,officiatt or employee <br /> thereof,heshall deed,indemnity aW hold there and 66dItofthat ha mless ter suds ;and <br /> 5. That work shalt be performedby ther t andlor any representativeof the application in the County Right-* Way at the above <br /> indicated site with, a valid San Joaquin t y EncroadineAtf alit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms,conditim and restriction <br /> of this and any attached sheet,included as general or special III provisions, <br /> Sig Iieaht Titie , <br /> »»>>>>»»»y»»»y»»»»»»»»»>FIELD INSPECTMU CO S«««««««««««««««««««««< <br /> EXISTING CONDITI)IN$ <br /> 1. DRIVEWAY. None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None Q Existing—Type <br /> Other pipes in n�Wigkl6ortiood Yes No Approaches Cross Drain Side <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No ;�3kf Yes: V Style ❑ 2 Point ❑ Other ❑ Wxb Depth <br /> »»»»»»»»y»»>>»»»»»»»»»»»»>PERMITS REQt3MENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFRCommercial ❑ Agriculture ❑ Industrial <br /> Paved with "Min Depth A.C.over "Min Depth%"A.B.over <br /> Notes: ., , ` . . ' r`' , <br /> 1-7 <br /> 2. PIPES: Length of Pipe Required <br /> Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <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 /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth%-A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»>>»»»»>y>»»»»»»»»»»»>FEES««««««««««««c«««««<««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field In tion <br /> Driveway w/or w/o pipe $110.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 H Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> NSIPWWV'OR CESICLERICAI-IP118511.WKWZrERPSUCROACHMENTPERMITDRIVEWAY.WC (10" PaPW2 <br />