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THE APPUGAN fT HEREBY CERTIRES: <br /> 1. That he/she has read all the provisions of this Win,and that the desat#w ink in this Voc I abon arae corned to the best of <br /> his/her knowledge,and <br /> 2. That he/she is the owner of the respective property,or is quaf wd4or the off;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 hist failure to do the work wed ham;and <br /> 4. That in the event any claim of such liability is made against the Courtly of San Joann or arty oral,-off or era* <br /> thereof,he shall defend,indemnify and holdthem and each of#Frerri W:141 ssc ta;and <br /> 5. That work shall be performed by the applicant arul/or any representve c tiott.irt the count ' the�e <br /> indicated site with a valid San Joaquin t✓ourtt Encroacf en#Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work gibed in acoordanoe widt alt terms,condition and restrictim <br /> of this and any attached sheet,included as feral or special fit provions, <br /> Signatu of Appficant`r e <br /> »»»»»»»»»»»»»»»»»»»»»>FIELD INSPECTION d tsffS<cc«<-<<< <<<<<<<<<c«««ac«<<««««« <br /> 1. DRIVEWAY: None Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved or ❑. Pavetorl <br /> 2. SLOPING: Away from Pavement ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: None [ Existing—Type <br /> Other Pipes in neighborhood: Yes No Lj Approaches Lj Cross Drain Lj Size, <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-way Ah ' <br /> 7. DITCH: Yes (R"°'No ❑ If Yes: V Style;❑ 2 Point ❑ Other ❑ Depth <br /> »»»»»»»»>»»»»»»»»»»»»»»»>t EFdVRTS MEPt'€3««< ««c«-t«<<<<««<<«««<««.�<« <br /> 1. DRIVEWAY: SFR "mmeraai ❑ Agriculture M Industrial ❑ <br /> Paved with "Min[Depth A.C.over. � "Min Depth'W"A`B.over <br /> Notes: fc <br /> 2. PIPES: Length of Pipe Required �) 3 "' # 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: r era a� ! og / & � ° <br /> 3. HEADWALL: Yes ❑ No <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 /> »»»»»»»»»»»»»»»»»»»»»»»»»»» g««<««<�e««««e«««««<««<c««««««c<<<< <br /> Driveway Encroachment Permit base fee $100.00 , <br /> F4U ins ection <br /> Jon Driveway w/or w/o pipe $107.00 ❑ Paved Frontage $113,00+0.52/ft. <br /> Driveway w/box Culvert $175.00 Curb,Gu,aftw* _,$110.00+1.05/ft. <br /> M:ICENTRALSERVICE$rCLERICALIPUB•SV.WK\MASTER.PShENMACHWNTPERWTDRNEWAY.DOC (10109) Page2012 <br />