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1. That he/she has read all the provisions of this application,and that the motion it dulled in e�to� a� ; <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner,an€i <br /> 3. That he/she will assume full responsibility for all liability for persona;injury or damage to proper wtlich MOySM 006fft <br /> 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 Sate Joaquin or an <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for sudi cl ; <br /> 5. That work shall be performed by the applicant and/or any representative of the applir.atiort in f <br /> indicated site with a valid San Joaquin County Encroachment Permitand :LLFml <br /> 6. That if permission is granted as requested,he agrees to do the roc described in accordance i104 <br /> of this and an attach sheet,included as general or special III provisions. <br /> Signa a of Applicant Ttie <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS<«««««««««<«« < <+ «< « <br /> EXISTING CONOtrIO IS <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 [v/Existing—Type <br /> Other pipes in neighborhood: Yes No LJ Approaches Cross Drain Sipe <br /> 4. HEADWALL: Yes ❑ No [v]� <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way N4yL9__.1 <br /> 7. DITCH: Yes ❑ No 06 If Yes: V Style ❑ 2 Point ❑ Other <br /> ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS«««««««««t<«<,�<< << «<<<<< <br /> 1. DRIVEWAY: SFR ❑ Commercial [rf Agriculture ❑ Industrial <br /> Paved with 4 1�_ "Min Depth A.C.over "Min Depth Y4*A.S.aver <br /> Notes: r A101, +* <br /> 2. PIPES: Length of Pipe Required ` Ft.and Diameter of Pipe <br /> To be connected to any adjacent driveway pipe Yes ❑ No Q' <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No }fes <br /> 4. PAVED FRONTAGE: Paved with <br /> "Min Depth A.C.over °.Min Depth <br /> Measuring Feet in length and Feet in width <br /> »»»»»»>»»»»»»»»»»»»»»»»»»»»>FEES«««««««««««««««<<«««c< << < «pc t <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field InsDection <br /> Driveway w/or wlo pipe 2 $110.00 Paved Frontage $11&00+0 <br /> Driveway w/box Culvert $179.00 8 Curb,Gutter,&dewalk $1'13,bO+1., <br /> 11SJPWG0V.0RGISHARESCZWRA1 SERVICESICLERICALIPUBSV.WKWASTER.PSIENCROACMWPERWDRIVEWAY.DOC (14/09) Paqe202 <br />