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1. That he/she has read all the provisions of this application,and that the desdlptior i in <br /> his/her knowledge;and <br /> 2. That he/she is the owner of the respective property,or is qu ed to representthe owrer; d <br /> 3. That he/she will assume full responsibility for all liability for persona;injury ori to property why <br /> described above,or which may arise out of his/her fa�ure to do the work " <br /> provided heeein;ar�I <br /> 4. That in the event any claim of such liability is made against the Camly.of San Joaquin or any.de <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such <br /> cam;and <br /> 5. That work shall be performed by the applicant and/or any repfesentative of the application in ate <br /> indicated site with a vcl`id San Joaquin County Encroachment Perm and Com. 1 V � <br /> 6. That if permission is granted as requested,he agrees to do the wart,desmbed in accordance 4dith alt <br /> of this and any attached sheet,included as general or special til provisrons. ' <br /> Signature of Applicant Title <br /> Dig <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INS'PECTI M C AIENt'S««««««<<<«5,t <br /> EXISTING CONDI <br /> 1. DRIVEWAY: None <br /> ❑" Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor] ElPaved(goad) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement [Or Flat <br /> 3. PIPES: None ED ~Existing—Type <br /> Other pipes in neighborhood: Yes LJ No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No VP6 ' 1 <br /> 6. BARRIERS: along Right-of-Way1 <br /> 7. DITCH: Yes ❑ No GRI Yes V Style ❑ 2 Point ❑ Other ❑ ftth p <br /> eo <br /> »»»»>>>>»»»»»»»»»»»»»»»»»»PEWS REQUUF.hIENfS«««««««««ee«<2< «" <��<�< <br /> 1. DRIVEWAY: SFR 9,"lCommercial ❑ Agriculture ❑ Industrie <br /> Paved with "Min Depth A.C.over ""Min Depth%"A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe , <br /> } <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 Storni Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with x'Y "Min Depth A.C.overMin <br /> " th�/"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»>»»»>»»»»»»»»»»»»»»»»»FEES«««««««««««<<<<<<««t«« « < <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field_Ins n5� <br /> Driveway w/or w/o pipe $110.00 Paved Frontage . $1 <br /> Driveway w/box Culvert $179.00 ❑ {Curb,Gutter,§dewalk <br /> $11 <br /> XSJPYYGOVOROSWESCMTRALSMMMSICLMCALRSSV.WKNA*1MPS4QJCROACFMe4rPHihNTURJMAYI= (16" PawUQ <br />