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1. v 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 /> hisfher knowledge;and <br /> 2 That he/she is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. Thathelshe i+ l assume full responsibility for ail liability for persona;injury or damage to property which may arise out of the work <br /> desoibettabove,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,official or employee <br /> thereof,he shag defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be perbTried by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> i site writh a valid San Jrin County Encroachment Permit;and <br /> 6. That Nper saioajs Aed,he agrees to do the work described in accordance with all terms,condition and restriction <br /> Of this i as general or special III provisions. <br /> IPJ <br /> n SiffApollcaria e <br /> »»»»»»»>»»»»»»»»»»»»PtiELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: !, ❑ Dirt ❑ Gravel E Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> doge <br /> 2. SLOPING: I Agar Pavement ❑ Towards Pavement [ Flat ❑ <br /> 3. PIPES: ,, None Existing—Type <br /> Other in neighborhood Yes No Approaches Cross Drain Site <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No 2 <br /> 6. BARRIERS: along;Emit-cif-Way ' <br /> 7. DITCH: Y� ❑ No 0 if Yes: V Style 2 Point ❑ Other ❑ Width Depth <br /> dry <br /> »»»»»» »»»»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY:t)SFR ® Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over r' "Min Depth'/4'A.B.over <br /> Notes:. <br /> 2. PIPES: Length of Pipe Required f 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 0 <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth Y4"A.B. <br /> ►Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field <br /> Driveway wl or w/o pipe-$1 10.00 Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 H Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> X% N>GOV. CESICI.ERtcAUPUg.W.WKMASTERPW CROACNMENT PERMIT DRIVEWAKDOC (10109) Page 2 of 2 <br />