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I I IL lII I uvnly l I IL-I\LU I ULZr\I I FICo. <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'est of <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 /> 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 shall 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 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 any attached sheet includ as general or special III provisions. ` <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) Paved(good) ❑ <br /> 2. SLOPING: Away from Pavements Towards Pavement `' Flat ❑ <br /> 3. PIPES: None N Existing—Type <br /> Other pipes in neighborhood: Yes No Approaches U Cross Drain H Size <br /> 4. HEADWALL: Yes ❑ No Z, <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way V--A v <br /> 7. DITCH: Yes ❑ No Xlf Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial Agriculture ❑ Industrial F] <br /> C0 wC"Aa- <br /> Paved with C, " lin Depth A-C.over "Min Depth'/d'A.B.over <br /> Notes: <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 ❑ 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 3/4"A.B. <br /> Measuring 52 ' Feet in length andg ��i Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee L>, ov �Qy'�'� +0 ' � �O •�' "'�'J � <br /> Field Ins ectionDriveway w/or w/o pipe Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert 8 Curb,Gutter, Sidewalk $113.00+1.08/ft. <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIVEWAY.DOC (10109) Page 2of2 <br />