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I ht AF FLIUAN I ht:Ktt3y ULK 11F ltS: <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 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 out of ofoh alherbailufor re to do the work injury ov ded or here he to erein; <br /> which may arise out of the work <br /> described above,or which may arise <br /> and <br /> 4. That in the event any claim ofnsn such ainbdil�oYld made them and elachthe <br /> of them harmless County forof San asuch uin or any <br /> andartment,official or employee <br /> thereof,he shall defend,indemnify <br /> 5. That work shall be performed by the pCountt Encroachment erepresentative <br /> sent tivedf the application in the County Right-of-Way at the above <br /> indicated site with a valid San JoaquinY <br /> 6, That if permission is granted as requested,he agrees or special 11 provisions.scribed in accordance with all terms,condition and restriction <br /> of this and a y attached she elude a <br /> Signature of Applicant Title <br /> ate <br /> »»»»»»»»»»»»»»»»»»»»»>FIELDISE CON COMM <br /> ENTS«««««««««««««««««««««< <br /> ING <br /> A Aggregate F1 Paved(poor) F1 Paved(good) ElNS <br /> 1. DRIVEWAY: None [� Dirt E] Gravel E] 99ate Base 9 <br /> � ❑ <br /> 2. SLOPING: Away from Pavement ✓[ Towards Pavement ❑ Flat t �� <br /> Existing–Type - A�' �'� %?°° ,. <br /> 3. PIPES: None A roaches � Cross Drain Size <br /> Other pipes in neighborhood: Yes No PP <br /> 4. HEADWALL: Yes ❑ No 0 <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way Depth <br /> 7. DITCH: Yes FJ No If Yes: V Style ❑ <br /> 2 Point ❑ Other ❑ Width P <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> DRIVEWAY: SFR <br /> Commercial ❑ Agriculture ❑ Industrial F11. ®', <br /> ' "Min Depth A.C.over "Min Depth'/4'A.B.over <br /> Paved with � <br /> Notes: �,- <br /> /</i r <br /> Length of Pipe Req `e inch(es) <br /> 2. PIPES: 9 Required Ft.and Diameter of Pipe <br /> To be connected to any adjacent driveway pipe Yes ❑ No 0_. <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No LJ <br /> "Min Depth A.C.over�— "Min Depth'/:'A.B. <br /> 4. PAVED FRONTAGE: Paved with Feet in length and Feet in width <br /> Measuring <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 ;O�Z <br /> > Paved Frontage $116.00+0.531ft. <br /> FelEDS� <br /> $110.00 113.00+1.08/ft. <br /> /or w/o pipe $179,00 Curb,Gutter,Sidewalk $ <br /> /box Culvert Page 2of2 <br /> 11SJPWGOV.ORG\SHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY-DOC (10109) <br />