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I Ht AFTLIUAIN I HLKLbY ULK I II-ILS: <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 oic <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 permiss`n is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of and a y attpched sheet,included as g neral or special III provisions. <br /> Signature of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> C6 06,Kek <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base ❑ d•(poor) Er Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ff""Flat ❑ 1 <br /> 3. PIPES: None Existing-Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No ❑ Curb, � �rz c�a/f <br /> 6. BARRIERS: along Right-of-Way doi, <br /> 7. DITCH: Yes ❑ No ©If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREM ENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial [►"Agriculture ❑ Industrial ❑ <br /> Paved with O "Min Depth A.C.over V "Min Depth Y4"A.B.over <br /> Notes: f '/ �/O�r�[ vd�� <br /> ��- <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 El/' <br /> Drainage Inlet Required Yes ❑ No 9_0 <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> r <br /> Notes: �� �e�a,��^ � ,�� � 01t�, � ,rrS 5�'�r -�, . //7 le <br /> 3. HEADWALL: Yes ❑ No E <br /> 4. PAVED FRONTAGE: Paved with *` ' "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 ? - <br /> Fie d Ins ection <br /> Driveway w/or w/o pipe $110.00 H <br /> Paved Frontage $116.00+0.53/ft. <br /> Driveway wlbox Culvert $179.00 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> %\SJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br />