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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 permission is granted as requested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> of this an ny attache sheet,included as en_era-Lorspecial III provisions. <br /> i natu a of pficant ' e Uate <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None 9Dirt ElGravel El AggregateBase ❑ Paved(poor) ❑ Paved(good) r] � 45(2 fiJ v`' <br /> 2. SLOPING: Awa from Pavement ❑ Flat <br /> Away ❑ Towards Pavement <br /> 3. PIPES: None ©`r Existing—Type L11 <br /> Other pipes in neighborhood. Yes No Approaches Cross Dram Size <br /> 4. HEADWALL: Yes ❑ No 0� <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> ©�" <br /> 6. BARRIERS: along Right-of-Way don e <br /> 7. DITCH: Yes Ly' No ❑ If Yes: V Style EjA 2 Point ❑ Other ❑ Width 7 � Depth / 5 <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR <br /> © Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with Z. "Min Depth A.C.over y "Min Depth'/4"A.B.over <br /> Notes: 7 ) �7E '11 GJ'j/G7 kl—/J .5 J <br /> e 4)r5/. err, t7c y ,14,// /? /����y` 1r /4� </&-1 C/ 19 <br /> 2. PIPES: Length of Pipe Required Ft.and Diameter of Pipe 7f inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No ❑ Q <br /> Drainage Inlet Required Yes ❑ No ©--� <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: I Noli- 1;e4,/ lei%vi't�a / P /hay Ileee /V 4e <br /> �/� /� Y <br /> o f�'F 6i��`��7 /t Cl✓%XPi✓c I/ lS �l�[' d C> , Zr <br /> 3. HEADWALL: Yes ❑ No ❑' <br /> 4. PAVED FRONTAGE: Paved with N "Min Depth A.C.over "Min Depth'/4°A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»»»»»»»»»»»»»»»»»»»»»»»FEES««««««. ««««««««««««««««««« <br /> 135:°6 UG <br /> Driveway Encroachment Permit base fee $ 5-60 � �25�, -3 77 ' <br /> Fie d Inspection X21,66T <br /> Driveway w/or w/o pipe UW 90 ed Frontage $116.00+0.53/ft. <br /> Driveway w/box Culvert $179.00Curb,Gutter,Sidewalk $113.00+ 1.08/ft. <br /> IISJPWGOV.ORGVSHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10/09) Page 2 of 2 <br />