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1. That he/she has read all the provisions of this application,and that the description included in this applicatiaru are cornea do the but of , <br /> his/her knowledge;and <br /> 2. That he/sty is the owner of the respective prolparly,or is quallified to represent the owner,and <br /> 3. That he/she will assume full responsibility for all Bari for Persona;injury or damage to property which may arise out of the work <br /> described above,or which may arise out of hisiher far a to db the woik pmt hereln;and <br /> 4. That in the event any claim of such liability is made against the County of Sarr.Jloa <br /> quin,or arty- artru at, <br /> thereof,he shalldnd;indemnify and hold them ma each of them harm[ for <br /> 5. That worts shall be performed by the applicant a AW anyrepresentativeof the application in the CW*R o <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permission is granted as requesd,he agrees to do the work described in accordance with all,Vis, I r <br /> of tltis and any a�sheet;imhOod as gerwral or s al ill pid�. <br /> 67 <br /> Signature of Applicant Title Datt <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FELD.00PECTION <br /> EX43TilMG O DtTlONS <br /> 1. DRIVEWAY: None ?0'Dirt ❑ Gravel ❑ Agggregate Base ❑ Paved(poor) ❑ Paved(good) [] <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement Flat <br /> 3. PIPES: None Existing—Type <br /> Other pipes in flighborhoal: Yes No L&I A roaches M Cross brain 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 Er If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»>»»»»»»»»>PF. ITS REQLQPX:MENO'S««««««««<"<<<<d<<«« ««<<<«« <br /> 1. DRIVEWAY: SFR lug' Comrnercial ❑ Agriculture ❑ Industrial <br /> # Paved with - "Min Depth A.C.over q 'Min Depth Y<A.B.over <br /> Notes: 'eve ' %h& 4 <br /> 2. PIPES: Length of Pipe Required IA- Ft.and Diameter of Pipe *a irirh(es} <br /> To be connected to any adjacent driveway pipe Yes ❑ No [Y , <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: _ °.`j 'S" (with proposed) Toth Number of Storm Drain Inlets: ' <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with r}j "Min Depth A.C.over "Miro t)epth 3/s A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»>»»»>>»»>FEES«««««««««««<t«««««C<c<«««««««« <br /> Driveway Encroachment Permit base-fee $125.00 <br /> Field Ins 'on <br /> 13rivewayw/or w/o Pipe $110. Paved Frontage $116.00+0.53fi1t <br /> Drivewayw/box Culvert $170.00 ❑ Curb,Gutter,SidWa_1k $113. +1.0". <br /> WWWGOV.ORG1SWESCENTRAISERVICESICLERC&"-SV MWASTERPSENMOACHWU PERMIT DRP&WAY.DOC (100) Page 2 of 2 <br />