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1• That he/she has read all the provisions of this application,and that f desaaa in= in this <br /> his/her knowledge;and bftblAof. a <br /> 2. That he/she is the owner of the respective property,or is qua/►`W,to mpres$ft,t4he ower,and, <br /> 3. That he/she will assume full responsibility for all liability for persona; <br /> or damage to ptopeq vdvofi <br /> described above,or which may arise out of his/her failure to do the work provkW Mrei&, <br /> and <br /> 4. That in the event any claim of such liability is made against theof <br /> San Joaquin oir my, <br /> thereof,he shall defend,indemnify and hold them and each of them mess for such <br /> 5. That work shall be performed by the applicant and/or any representative of the <br /> indicated site with a valid San Joaquin County Encroachment Perm€k ar�d <br /> 6. That if permission is gr as r ested,he agrees to do the work descn'bed in accordance <br /> of this and any ed sheet,inded as general or <br /> c 9 sperm til provisions. <br /> ignature of Applicant Title <br /> »»»»»»>»»»»»>»»»»»»»»>>>FIELD INSPECTION C <br /> EXISTING <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel O Aggregate Base ❑ paved(per) ❑ Pave(good) <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement [Flat Q <br /> 3. PIPES: None ❑ Existing–Type f ' <br /> Other pipes in neighborhood: Yes No Ap# oadtes Cross fin U Size <br /> 4. HEADWALL: Yes ❑ 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 NO <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS«<««««<«««<<<<<4««««14<« <<< <br /> 1. DRIVEWAY: SFR [ 'Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with t "Min Depth A.C.over ' <br /> — -Min Depth%*A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe <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 Stm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with ^ <br /> Min Depth A.C.over "Min Dept%w"AB, <br /> Measuring Feet in length and Fcet in w <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES«««««««««<«««««««««<<<C<<< <«4<< < <br /> Driveway Encroachment permit base fee $125.00 <br /> Field fns ection <br /> Driveway w/or w/o Pipe $110.00 Paved Fron 1g Op 0.53 , <br /> Driveway w/box Culvert $179.00 HCurb,Gutterwalk $113.1 +1. <br /> IWPWGOV.ORGISHARESICENTRA SERVICESICLERICALIPU&SV.WKWASTER.PSIENCROACNMENTPEtMITORIVEWAY.00e (IM Page 2of2 <br />