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THE APPLICANT HEREBY CERTIFIES: <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 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 per 'ssion is granted a equested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this an �' y attached ,' luded as general or special III provisions. <br /> Signat r of Applicant Title Date <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None [ill-,, Dirt Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement 10/ Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None [Existing—Type <br /> Other pipes in neighborhood: Yes 11-f No LJ Approaches LJ Cross Drain H Size <br /> 4. HEADWALL: Yes ❑ No [al`, <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [► <br /> 6. BARRIERS: along Right-of-Way <br /> � f <br /> 7. DITCH: Yes No ❑ If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth �'- <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR ❑ Commercial 2---"Agriculture ❑ Industrial ❑ <br /> Paved with "Min Depth A.C.over "Min Depth Y4"A.B.over <br /> Notes: ��� �� �����f�fi� ✓ [14t) �5 el, . �l, � S'41- ��-y f�X"', , 17 <br /> ze,>oj b,-ees 0,7 sj,11'ej c��� �'�' D��'C/ Jl."P oeilV s11411 he -1b1yP0C/ -fiv aje t' wile lice-of S��tf�� <br /> LI iS nCE > rz✓ie*41 ae(ef (a d"/p, ATIO /Ti e.-1 3 <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: '� �'`, <;Tl � �rC //� /�e�b"�'f'1 ,'J7T /�`9/� G'J'�'� S �/. C C> .�t' �'�t%/ ���;.'E A-k- le <br /> C-�Iy.�� A Ile 116 r) <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth 3/4'A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> 17'eW Inspection <br /> Driveway w/or w/o pipe $110.00 ❑ Paved Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00 Curb,Gutter,Sidewalk $113.00+ 1.08/ft. <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10109) Page 2 of 2 <br />