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1. That he/she has read all the provisions of this application,and that the description included in this application to ©f <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 /> property <br /> described above,or which may arise out of his/her failure to do the work provided herein; ndwhin mai'arise c # # yyork <br /> and <br /> 4. That in the event any claim of such liability is made against the County of San Joaquin or <br /> any offidatorempbyw <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim; department <br /> ;and <br /> 5. That work shall be performed by the applicant and/or any representative of the application in the Court <br /> indicated site with a valid San Joaquin County Encroachment Permit and County <br /> 6. That if permission is granted as requested,he agrees to do the work described in accordance with all temps,condition aW <br /> of this and any attached sheet,included as eneral or special ill provisions. restictidn <br /> ature of Applicant Title f Date <br /> »»»»>»»»»»»»»»»»>»»»»»>FIELD INSPECTION COMMENTS«««««««««««««c<C««« «« <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flag <br /> 3. PIPES: NoneExisting—Type <br /> Otheres in neighborhood: Yes NoApproaches Cross D ' <br /> ram Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ElNo�} <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»>»»»»»»»»»>PERMITS REQUIREMENTS«««««««««<<<<< <br /> 1. DRIVEWAY: SFR ❑ Commercial P <br /> Agriculture ❑ Industrial F1Paved 'th "Min Depth A.C.over "Min Depth Y."A.B.over <br /> --4 <br /> Notes: a rel os Q <br /> 2. PIPES: Length of Pipe Required iv Ft.and Di ter of Pipe <br /> To be connected to any adjacent driveway pipe Yes ❑ No 011 <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 Y.`A.B. <br /> Measuring Feet in length and Feet in width <br /> >>>»»»»»»»»»»»»»»»»»»»»»»»»»>FEES«««««««««««««««««««a«««««««< <br /> Driveway Encroachment Permit base fee $125.00 <br /> r � <br /> Field Ins ection <br /> Driveway w/or w/o pipe $110.00 Paved Frontage $116.00+0.53/ft <br /> Driveway w/box Culvert $179.00 ❑ Curb,Gutter,Sidewalk $113.00+1.08/it. <br /> VWPWWV.ORW ARESICeORAI.SQ2YICESICLERICA RB-WWKW STMPSOCROACHMEWPBWDRMWAYAOC (1 09) <br /> Page 2 of 2 <br />