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1. aVthe *AMs of this application,and that the description included in this application are correct to the best of <br /> 2 .fid lelabeisthe owner of the respective property,or is qualified to represent the owner,and <br /> 3 That�w �e full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> Orvd*hmyate:out of his/her failure to do the work provided herein;and <br /> 4 That in Ills ey of such{i�lity is made against the County of San Joaquin or any department,official or employee <br /> ltwed,tia Vilify Iand hold them and each of them harmless for such claim;and <br /> 5 That l rk �pby the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated si b a SM,joaquin County Encroachment Permit;and <br /> 6 TtA if is anted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> Wjudqd as general or special III provisions. <br /> offt <br /> 2I bC--f <br /> 1, Ualu <br /> t Title <br /> » y 5 » IELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> »»>>>»»»»»»>y»» » EXNG CONDITIONS1_ ! ❑ Dirt F1 Gravel D Aggregate Base Paved(poor) El DRIVEWAY: <br /> (good) ❑ <br /> 2 SLEEPING: Arn pavement❑ Towards Pavement [ Flat ❑ <br /> r Type roaches Cross Drain Size_____ <br /> 3 PIPES: Yes No App <br /> In <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ j f 4 � <br /> 6. BARRIERS: along Right-Of' a)t <br /> Yes 0 <br /> 7. DITCH: <br /> hkl Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»> �»'» �>}>>»»>y»>y»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> -,, , <br /> 1. DRIVEWAY: SM`❑ Commercial U" Agriculture ❑ Industrial E] <br /> "Min De th3/<"A.B.over <br /> Pave!wb "Min Depth A.C.over p <br /> Notes: - I ,taa-. G !l ! `/ <br /> 414 P it k`l;, d <br /> i'"., inch(es) <br /> 2. PIPES: Lenge of Requlred <br /> Ft.and Diameter of Pipe <br /> To be ownected to any adjacent driveway pipe Yes ❑ No <br /> Dr*"e Inlet Requked Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> i <br /> i <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No I <br /> .+� "Min Depth A.C.over "Min Depth'/4"A.B. <br /> 4. PAVED FRONTAGE: Paved with ` <br /> Measurmg Feet in length and Feet in width <br /> >>>>»>»»»»»»»»»»»»»»»»»»»»»»»>F E E S««««««««««««««««««««««««««« <br /> Driveway Encroachmalt Per6d base fee_L _$125.00 <br /> F" Paved Frontage $116.00+0.531ft. <br /> ,d or w/o p� $110.00 ❑ Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> Driveway wftx Colvert $179.00 <br /> g W_ftWA$TMP$1ENCROACHMENT PERtAT DRIVEWAY.DOC (10M) Page Z of Z <br /> kZVWGOv.ORGZHARE <br />