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1. That he/she has read all the provisions of this application,and that the description included in this application are correct tc the best of <br /> hMw 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 Wshe will assume full responsibility for all liability for persona;injury 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,official or employee <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shalt be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and any abadWDAet,included as general or special III provisions. <br /> Signature of Applicant Title ate <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY. None ffe Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Array from Pavement [0�" Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None R Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes E] No [ °` <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [� <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes �No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >>>y»»»>»»»»»»»»»»»»»»»»»»>PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Payed witha: "Min Depth A.C.over "Min Depth'/<"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required ; Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No B <br /> Drainage Inlet Required Yes ❑ No B' <br /> Total Length: _ (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: '� < .1 <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 /> »»»»»»»»»»»»»»»»»»»»> »»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit Mase fee $125.0 �5 6 <br /> J <br /> Field Irmection <br /> Driveway w/or w/o pipe $110.00 H Curb, Frontage <br /> Sidewalk $113.00+0.08/ ft. <br /> Driveway wlbox Culvert <br /> 1WpWC,ov.ORGWrHgMPLOMAI,SERUICESSaERICALIPUM.WKVAASTER.PMNCROACHMENT PERMIT DRNEWAY.DoC (10109) Page 2 of 2 <br />