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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 ofthe 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 and any attached sheet,included as general or special III provisions. <br /> S(gnature ofAppl(cant Title ate <br /> »»»»»»>»»»»»»>»»»»»»»»>FIELD INSPECTION COMMENTS«««««««««««««««««««««< <br /> EXISTING CONDITIONS <br /> 1. DRIVEWAY: None © Dirt ❑ Gravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING: Away from Pavement 0Y'_Towards Pavement ❑ Flat ❑ <br /> 3. PIPES: None Er Existing—Type ,114 <br /> Other pipes in neighborhood: Yes Lj No Approaches U Cross Drain U Size <br /> 4. HEADWALL: Yes ❑ No [g`_ <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No <br /> 6. BARRIERS: along Right-of-Way I(Io»e <br /> 7. DITCH: Yes ❑ No 091 Yes: V Style ❑ 2 Point ❑ Other ❑ Width <br /> Depth <br /> »»»»»»»»»»»»»»»»»»»»»»»»PERMITS REQUIREMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Ltd Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with Z "Min Depth A.C.over "Min Depth'/"A.B.over <br /> Notes: t!'e"klrr� iv r �� S.J. uh r, _rx/ Aw a. X '/7 <br /> Ch.f�ldC Cl�"ic mar s .}'/p 2 � •7U G�✓Cin <br /> 2. PIPES: Length of Pipe Required 1114 Ft.and Diameter of Pipe <br /> inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No [+� <br /> Drainage Inlet Required . / Yes E3 No ©� <br /> Total Length: M/A (with proposed) Total Number of Storm Drain Inlets: 1-1/14 <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with '`��A "Min Depth A.C.over " 3 " <br /> Min Depth /, A.B. <br /> Measuring Feet in length and Feet in width <br /> »»»»»>»»»»»»»»>>>>»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway Encroachment Permit base fee $125.00 <br /> Field Ins ection <br /> Driveway w/or w/o pipe $110.00 Paved Frontage <br /> Driveway w/box Culvert $179.00 $116.00+0.53/ft. <br /> Curb,Gutter,Sidewalk <br /> IMPMOV.ORGISHAREMCENTRALSER ACESICLERICALIPUB-SV.WKIMASTER PSIENCROACHMENT PERMfr DRIVEWAY.DOC (10109) Pae 2 of 2 <br /> $113.00+1.08/ft. <br /> 9 <br />