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1. That helshe has read all the provisions of this application,and that the description included in this application are correct to the be�t-bf-- -- <br /> hisl w Mowledge,and <br /> z That heishe is the owner of the respective property,or is qualified to represent the owner,and <br /> 3. That helshe 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 work 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 shah 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 Perrriit;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 /> Of this and any attached sheet,included as general or special III provisions. <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS««««««««««««« «««««««« <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt 0 Gravel [0" Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None j E)asting—Type ' <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL Yes ❑ No Qr <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No E <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes ❑ No 9 If Yes: V Style 0 2 Point ❑ other ❑ Width Depth _ <br /> »»»»»»>»»»»»>»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial E Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over '4 "Min Depth Y4"A.B.over <br /> Notes. 3otc dloie4vov A,6 ae <br /> dho5 I-e-ttr`T" i5 / i%'Le �: r^`,� ,y,>�. ... 'r#°'�aC"t "'.fi`, <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No ( ' , <br /> Drainage Inlet Required Yes El No 0 <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> X <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««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Inspection <br /> Driveway wlor w/b lbox Culvert $179.00 Curb Gutter,ved $116.00*0.53/R <br /> 8 $113.00 1.08/ft. <br /> UJVG0V.0RG9VRE9canPAsmiCN WUBSv PERANT DRNEWAY.DOC (IM Page 2 of 2 <br />