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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 to the best of <br /> his/herlcnawtedge;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 his/her failure to do the worts 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 shag defend)indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall 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 perrrtission is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> Of this acrd any attached Peet incl as enerai or special III provisions. <br /> --sign pplicant Title <br /> ate <br /> >>>»»»»»»»»»»»»»»»»»»»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <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 &KEAsting—Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size _ <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> r <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 Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth%"A.B.over <br /> Notes: N4 � .'' 1 <br /> 2. PIPES: Length of Pipe Required ° r p" Ft.and Diameter of Pipe `;r`k inch(es) <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 Storm Drain Inlets: <br /> Notes: <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 base fee $125.00 <br /> Field Inspection <br /> Driveway wl or Wo pipe $110.00 Paved Frontage $116.00+0.531% <br /> LJ Driveway Wbox Culvert $179.00 8 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> MPWGOVORC&IA WCDffWMMCESICLMCALIF'uMWKIMASTER:PSOCROACHMMPERMITDMEWAY.DOC (10109) Paw2oQ <br />