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ΤΗΕ APPLICANT HEREBY CERTIFIES: <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />That he/she has read all the proνisions of this application, and that the description included in this application are correct to the best of his/her knowledge; and <br />That he/she is the owner of the respectiνe property, or is qualified to represent the owner; and <br />That he/she will assume full responsibility for all liability for persona; injury or damage to property which may arise out of the work described aboνe, or which may arise out of his/her failure to do the work proνided herein; and <br />That in the eνent any claim of such liability is made against the County of San Joaquin or any department, official or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; and <br />That work shall be performed by the applicant and/or any representatiνe of the application in the County Right-of-Way at the aboνe indicated site with a νalid San Joaquin County Encroachment Permit; and <br />That if permission is granted as requested, he agrees Ιο do the work described in accordance with all terms, condition and restriction of this and any attached sheet, included as general or special 111 proνisions. <br />c � �.,,. C-/IG-&ι r \Signature οΑρίϊcanίτiϊ � ate <br />>»»>»»»»»>»»»>»»>»»»»»»FIELD INSPECTION (OFFICE USE ONL Υ)«<«<«<«<«««««<«««<«««« <br />EXISTING CONDITIONS <br />1.DRIVEWAY: None Ο DirtM Graνel Ο Aggregate Base Ο Paνed (poor) Ο Paνed (good) Ο <br />2. SLOPING:Away from Paνement Ο Towards Paνement Ο Flat .#J <br />3.PIPES:None P.J.. Existing -Type _�-.,....,..--,-,--,-fvr1ι>,-,,t--,-----,-........,--,,,...-�,....,..-τ-...---=--------Other pipes in neighborhood: Yes Ο Νο � Approaches Ο Cross Drain Ο Size ___ _ <br />4.HEADWALL: Yes O Νο � <br />5.ASPHAL Τ CONCRETE DIKE: Yes O Νο � <br />6.BARRIERS: along Right-of -Way ___________________________ _ <br />7.DITCH:Yes O Νο � lf Yes: V Style O 2 Point O Other O Width __ _ Depth __ _ <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>PERMITS REQUIREMENTS<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />1.DRIVEWAY: <br />Notes: <br />SFR � Commercial Ο <br />Paνed with 'J-. <br />Agriculture Ο lndustrial Ο <br />"Min Depth A.C. oνer __ 4 ____ "Μίn Depth ¾" Α.Β. oνer <br />2.PIPES:Length of Pipe Required __________ Ft. and Oiameter of Pipe ___ #ι'-+'½4.....__ _____ inch(es) 7 Το be connected to any adjacent driνeway pipe Yes Ο Νο b/4 <br />Drainage lnlet Required Yes Ο Νο .ίΏ_ <br />Total Length: _______ (with proposed) Total Number of Storm Drain lnlets: _____ _ <br />Notes: <br />3.HEADWALL: Yes O Νο Μ, <br />4.PAVED FRONTAGE:Paνed with _____ "Min Depth A.C. oνer " Min Depth ¾" Α.Β. Measuring Feet in length and ______ Feet in width <br />>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>FEES<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <br />Driνeway Encroachment Permit base fee $135.00)11 1,�if'. � <br />Field lns ection riνeway w/ or w/o pipe ______ $140.00 Driνeway w/box Culνert $181.00 <br />Ρ IEtΙCROACliMEΊHS\.',,t,\S1ef fαm1-Tetφla'8ι\ξHCROACHUΞr1, ΡΕRΙΑΤ ORIVE\'iAY doc:(O&'Ot) <br />Ο Paved Frontage-,--...,,... ___ $116.00 + 0.53/ft. Ο Curb, Gutter, Sidewalk $140.00 + 1.16/ft.