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THEPUGAWtV�EVORMFIES: <br /> 1 ,i reel tf provisions of this application,and that the description included in this application are correct to the best of <br /> 2. <br /> Tta#�We isthe.Ownw of`the respective property,or is qualified to represent the owner;and <br /> 3 Tr&lh"herlwitosbim fullresponsibility for all rtability for persona;injury or damage to property which may arise out of the work <br /> above,ot~y llt a rrgyarise out of his/her failure to do the work provided herein;and <br /> 4 ftt in.ftowt a <br /> Wdaim of such ability is made against the County of San Joaquin or any department,official or employee <br /> *��-kdetwlfyand hold-them and each of them harmless for such claim;and <br /> TW,w be epi by ftapplicant and/or any representative of the application in the County Right-of-Way at the above <br /> y� County Encroachment Permit;and <br /> 6 rs gr I as regrtested,he agrees to do the work described in accordance with all terms,condition and restriction <br /> 6t ft And gq eral or special III provisions. <br /> Sighaturs of AWcant Title J7�_C_ ate <br /> >>>>>>»,>»>»>»may»»y»»FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: N e ❑ Dirt aK 01 Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLEEPING: Away, from Pavement Towards Pavement ❑ Flat <br /> /Jn <br /> 3. PIPES: <br /> Non <br /> 3. --Tyle /wa'r <br /> Yes No Approaches Cross Drain Size <br /> 4. HEWWAL L:, Yes ❑ No <br /> 5. ASPHALT C04GR "E'IE:,Yes ❑ No <br /> 6. BARRIERS: aloe Ifil t4 may ' <br /> 7, DITCH: Yes ❑ No Yes: U Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> y»>y,y»» » »> .»»y;>y>>>>>»»>y»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> i. DRIVeMAY:, " �orrrrnereal ❑ Agriculture ❑ Industrial ❑ <br /> Pawed wiM "Min Depth A.C.over 'Min Depth 3/4"A.B.over <br /> es <br /> inch <br /> 2 PIPES: Ler of Pipe Required fi , Ft.and Diameter of Pipe ( ) <br /> To be.connected to any adjacent driveway pipe Yes ❑ No ❑ <br /> Drage lnlet required Yes ❑ No ❑ <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes <br /> 3, HEADWALL: Yes Q NO r� <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 /> »»»»»»»» »»»,»»,>,yy»»>>»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachmerd Permit base fee <br /> F 10 ❑ Paved Frontage $108.00+0.50/ft. <br /> DrivewayvJ or w/o pipe Curb,Gutter,Sidewalk $105.00+1.03/ft. <br /> Driveway wibox Culvert ' $ 7.00 <br /> Y1fOW B T9A1IAT£SSfEXF0A0Wff PEW DVOVAY.Cac.PW <br />