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`1. Vknlow1'(e'd'ge; <br /> sread all the provisions of this application,and that the description included in this application are correct to the best of <br /> hi and <br /> 2. Thao/she is the owner of the respective property,o is qualified to represent the owner and <br /> 3. That(�i�she will assume full responsibility for all liability for perso ,' ' ge to property which may arise out of the work <br /> desc fibbed 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 alid San Joaquin County Encroachment Permit;and <br /> 6. That if permi io s granted as quested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this and a ached she ,included as gen7,. <br /> or special III provisions. <br /> i dtr, " o/Lr/ �-Z.-17— <br /> ignature of pplicant Title ate <br /> »»»»»»»»> »»»»»»»»»»»>FIELD INSPECTION COMMENTS««««««««««<4««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None ❑ Dirt []/GraVO ❑ Aggregate Base ❑ Pave (poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away fr;7E)isting— <br /> ement El Towards Pavement El Flat [ <br /> 3. PIPES: None Type <br /> e_ <br /> Other pipes in neighborhood: Yes LJ No Approaches LJ Cross Drain LJ Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way o» <br /> 7. DITCH: Yes ❑ No Eg'If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> >»»»»»»>»»»>»»»»»»»»=•»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial ❑ Agriculture Industrial ❑ <br /> Paved with 2 "'Min Depth A.C.over "Min D�pth%"A.B.over / <br /> Notes: C� 1' Viv) Gv/R-/� S �� f7c11 . <br /> � U <br /> c� <br /> 2. PIPES: Length of Pipe Required _ '� Ft.and Diameter of Pipe 1A inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [ � <br /> Drainage Inlet Required Yes No 1� <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with d1w "Min Depth A.C.over "Min Depth%"A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 37 <br /> b <br /> FLeld Inspection <br /> Driveway wl or w/o pipe $'110.00 Paved Frontage $116.00+0,53/ft <br /> Driveway w/box Culvert $'179.00 ❑ Curb,Gutter,Sidewalk <br /> $113.00+1.08/ft <br /> IISJPWGOV.ORGISK4RESICENTRALSERVICESICLERICALIPU&SV.WKWIASTER.PSIENCROACRJENTPERMITDRIVEWAY.DOC (10109) Page 2ot2 <br />