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1. That heifstie has read all the provisions of this application,and that the description included in this application are correct to the best of <br /> hMw know:and <br /> 2 That h&fshe is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. TtrAhe*ie wfil assure full responsibility for all liability for persona;injury or damage to property which may arise out of the work <br /> desc&e ;above,or whir may arise out of his/her failure to do the work provided herein;and <br /> 4 That in the event any dim of such liability is made against the County of San Joaquin or any department,official or employee <br /> thereof,he sha defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5 That work shaft be perbTned by the applicant and/or any representative of the application in the County Right-of-Way at the above <br /> indicated site v a vdd San Joaquin County Encroachment Permit;and <br /> 6. if p&TIiSMft-is gr ested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of ft a4wo any as general or special III provisions. f <br /> nahn of Applicant Title ate <br /> »»»»»»>»»y»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: NSM [} Dart ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2 SLOPING: Away from Pavement Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Existing—Type <br /> Other pipes in ndgtiW ood Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No IJ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <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 J jK Cornrnercial ❑ Agriculture ❑ Industrial ❑ <br /> Depth'/<"A.B.over <br /> Paved with "Min Depth A.C.over "Min De p <br /> a <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> •. Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No E <br /> Drainage Inlet Required Yes ❑ No ❑ <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No 3 " <br /> "Min Depth A.C.over Min Depth /4 A.B. <br /> 4. PAVED FRONTAGE; Paved with length and Feet in width Feet in fen <br /> Measuring g <br /> »»»>»»»>»»»»»»>»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Ml $110 00 H <br /> Paved Frontage $116.00+0.531% <br /> /w w/o pipe 179 00Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> /bax Culvert $ <br /> `WpWC I LIp�JB-SV PERMI7DRIVEWAY.DOC (iQN9) <br /> Page 2 of 2 <br />