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THE APPUCAN T HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the included in this <br /> his/her knowledge;and are Med to the best of <br /> 2. That he/she is the owner of the respective property,or is quafiied to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for persona;inlury or damage to property which r. arise out of the y <br /> described above,or which may arise out of his/her failure to do the wo*obvi1ed f�ein;and <br /> 4. That in the event any claim of such liability is made against the County of San Joaquin or an <br /> thereof,he shall defend,indemnify and hold them and each of them harmless for such dakn; e <br /> 5. That work shall be performed by the applicant and/or any representative of the application in the County lett-ol-Way at the above <br /> indicated site with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if permissi n is granted as requested,he agrees to do the work described In accordance with all tis condition and restriction, <br /> of this and ttached shee, luded as general or special III provisions. <br /> Signature orApplicant Title Uam <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION ComMEtM<<r«<t«««t«««<- a«««<,c <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None [D Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) 0. <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat❑ AIIX <br /> 3. PIPES: None Existing—Type <br /> Other pipes in neighborhood: Yes No LJ Approaches Cross Drain Size <br /> 4. HEADWALL: Yes ❑ No [� <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way <br /> 7. DITCH: Yes [l"°` No ?, ' <br /> ❑ If Yes: V Style ❑ 2 Point ❑ Other.❑ Width 1'e6t3a�'o,ya,� Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTSe«««««««««<�<<,Oc««««< <««<<.t <br /> 1. DRIVEWAY: SFR ED Commercial ❑ Agriculture ❑ Industrial <br /> Paved with - "Min Depth A.C.over "Min Depth Y4"A.B.over <br /> Notes: �,, a. , <br /> f <br /> t <' <br /> 2. PIPES: Length of Pipe Required ' Ft.and Diameter of Pipe 1 <br /> 2 ++ tt11.n , inch*) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [o" <br /> Drainage Inlet Required Yes ❑ No R" <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes <br /> -� r �,.r, �, ,�}'.'3 .f,' l�"1t1,�7l �'�a-�t,� �'�✓,�, �s��w'/r'i� � <br /> ? .� aunt ,°u stir ✓ A w <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTArGE: Paved with "Min Depth A.C.over "Min Depth YV A.B. <br /> 1 Measuring Feet in length and Feet in width <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> »»»»»FEES««««««K«««««««««<<««««««<-<«««< <br /> Driveway Encroachment Permit base fee thy % <br /> Field Ins eat-110 <br /> riveway w/or w/o Pipe $107.0 Paved Frontage $113.00+0.52/ft. <br /> Driveway w/box Culvert 0 ❑ Curb,Gutter,Sidewalk $110,00+1.05/ft. <br /> M.kCENTRALSERVICES'.CLERICALPUB-SV.WKIWSTER.P$%ENCROACHMENT PERMIT DRIVEWAY.DOC (700) page 2of2 <br />