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I r-IC/ir'I"'LIIiHIV I r-ICKCC7 T LCK I IrICJ: <br /> 1. That he/she has read all the provisions of this application,and that the description included in this application are correct to the best oy <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 property which may arise out of the work <br /> is/her failure to do the work provided herein;and <br /> described above,or which may arise out of h <br /> 4 heaeof,the <br /> shalltdefenda indemnify a(nd(hold them anis made against <br /> each of them ham ess forof San asquin uch or any <br /> andepartment,official or employee <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 /> of this and a ttached t,in ded as general or special III provisions. Z 1 <br /> � -4— D <br /> - <br /> Signature of Applicant Title ate <br /> »»»»»»»»»»»»»»»»»»»»»>FIELDISE CION COIOMENTS«««««««««««««««««««««< <br /> ING <br /> NS <br /> 1. DRIVEWAY: None [P""Dirt ❑ Gravel ❑ Aggregate Base El Paved(poor) El Paved(good) El <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat 1,,O and� <br /> 3. PIPES: None [g"',Existing—Type roaches Cross Drain Size <br /> Other pipes in neighborhood: Yes No App <br /> 4. HEADWALL: Yes ❑ No Cr <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way Van t <br /> 7. DITCH: Yes F1No Yes: V le F12 Point E-1Other ❑ Width Depth <br /> [011Yes: Style <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR [i]/Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with Z "Min Depth A.C.over 1 n "Min Depth'/;'A.B.over <br /> Notes: <br /> 2. PIPES: Length of Pipe Required <br /> x/14 Ft.and Diameter of Pipe ��� inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No Ly <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No I <br /> / "Min Depth <br /> A.C.over "Min Depth'/4"A.B. <br /> 4. PAVED FRONTAGE: Paved with p Feet in width <br /> Measuring Feet in length and <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»F6EES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> I <br /> ld Ins ection $110.00 I� Paved Frontage $116.00+0.53/ft. <br /> Driveway w/or w/o pipe $179.00 H Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> Driveway w/box Culvert page2of2 <br /> USJPWGOV.ORGISHARES\CENTRALSERVICESICLERICAL\PUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10109) <br />