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1. That helshe has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> hWtw 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 he/she 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 hislher 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 shaf defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5_ That wont shag be performed by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicaW site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is gran as requested,h agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and ee era!or special III provisions. <br /> 4 icant Title Date <br /> >>>»»>>»»»»»»» »»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None Na''Dirt ❑ Graver ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement [Towards Pavement ❑ Flat ❑ <br /> r r <br /> 3. PIPES: NoneExisting—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No a' <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No �Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR f Commercial [] Agriculture ❑ Industrial ❑ <br /> j//JJ' Paved with 2 �y "Min Depth A.C.over h "Min Depth 114"A.B.over <br /> Notess. i✓'rfY,r. 4�d"''' f ! -•4r_ f Cal <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 .. <br /> Drainage Inlet Required Yes ❑ No E3"' <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No a <br /> 4. PAVED FRONTAGE: Paved with ° '.X "Min Depth A.C.over "Min Depth'/4"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 w/or w/o pipe $110.00 Paved Frontage $116.00+0.531ft. <br /> Ddveaway w/boxCulvert $179.00 H Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> 14SJ VC,OV.ORt iS MESkCeOPALSERVICEMLERMPJB,W.wKVAASTER.PSIENCROACMEW PERMIT Mr"AY.DOC (10/09) Page 2 of 2 <br />