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I. 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/her 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 <br /> described above,or which may arise out of his/her failure to do the work property may arise out of the work <br /> provided herein;and.. <br /> 4. That in the event any claim of such liability is made against the County of San Joaquin or any departmeri#,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 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 permission is granted as requested,he agrees to do the work described in accordance with all terms condition and restriction <br /> ofT74 <br /> ed sheet,i c ded as geneTI or special Ill provisions. <br /> nature of Applicant tie <br /> LW <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None [a"Dirt ❑ Gravel ❑ Aggregate Base ❑ paved <br /> (poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ID'~ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None ', Existing—Type <br /> Other pipes in neighborhood: Yes No <br /> Approaches U Crass Drain Size <br /> 4. HEADWALL: Yes ❑ No [ ' <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way w <br /> 7. DITCH: Yes ��No +,P <br /> ❑ If Yes: V Style 2 Point ❑ Other ❑ Wrdth , Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR 0'' Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over " 3 " <br /> Min Depth f< A.B.over <br /> Notes: <br /> . � '-, <br /> 2. PIPES: Length of Pipe Required - <br /> Ft and Diameter of Pipe t inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No g"' <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No ❑- �� ' ��` f'` <br /> �` 4V <br /> 4. PAVED FRONTAGE: Paved with _ '~ "Min Depth A.C.over " a " <br /> Mm Depth A.B. <br /> Measuring . Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»>,'->>>>>>>>>>>>>>>>>>>>>>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee_ _$125.00 <br /> 04 <br /> 42D_'nNnv_eeP_wWecajyiowwn/ <br /> st ,�¢Z3$. <br /> or w/o pipe $110.00Drivway /box Culvert— $17g 00 HCurb,Paved Frontage $116.00+0.53fft <br /> IISJPWGOV.ORGISHARESICENTRA!SERVICESICIERICALIPUB-S\I.WKIMASTER.PSIENCROACHMENTPERMTDRNEWAY.DOC (Ing) Gutter, <br /> Sidewalk +1.08/ft. <br /> Page 2 of 2 <br />