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THE rLPPLICAXT HEREBY ERTIFIES: F <br /> 1.That he/ohe ha:read all the pmvisions of this application,and that the descriptions included above arc correct to the bat of <br /> his/her knowledge;and <br /> 2.That he/she is the owner of the respective property,or is qualiucd to rcprescrrt the owner,and <br /> 3.That he/she will assume full mpotuibili,y far all(lability for personal injury or damage to property which may arae out of <br /> the work described above,or which may arise out of his/her failure to do the wort:provided for herein;and <br /> 4.That in the event any claim ofiuch liability is made_ziinst the County of San Joaquin or any department,official or employee <br /> thaco&he shall dc:'cad,ind,=Z)-a.;d hold th W and cash of th=hy!es z for such claim;and <br /> 5.That no work shall be performed by the applic:act and/or any repro sentntives of the applicant in the County Right-of-Way at <br /> the above indicated site without a valid Sia Joaquin County Encroaclumcnt Parsit;and <br /> ti.That; if permission is granted as requested,he agrees to do the wort:described in accordance with all terms,conditions and <br /> restrictions of this and any attached sheet, included as general or special 111 provisions. <br /> Siganature of Applicant -Title Date <br /> FIELD IN. SPECTOR CO:Nn1 I[ NTS <br /> »»>»»»»»»»> EXI S TI-t'G CONDITIONS «««««««««< <br /> 1. DRIVEWAY: None_L2�Dirt Gravel Age eaate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOPPT G: Away from Pavement Towards Pavement Flat <br /> 3. PIPES: None Existing - Type _ <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Ye; No <br /> 4. HEADWALL: ties IN,0 5. ASPFLA LT CO CRETE DIKE: Yes No <br /> 6. BARRIERS along Right -Of-Way <br /> 7. DITCH Yes_NToIV If Yes: V Style 2 Point_Other Width Depth <br /> »»»»»»»»»» PERA'4IIT REQUIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR X CO: .: RCL4L AGRICULTURE RDUSTRIAL <br /> PAVED with " Min. Depth A.0 over. "Min. Depth 3/4"A.B. <br /> ROC= with " Iva. Depth 3/4" A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft. and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes No� <br /> DRAINAGE Ii rLET REQUIRED YES NO <br /> Total Length: (with proposed Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with " Mitt. Depth A.0 over "MLiL Depth 3/4" A.B. <br /> measuring Fevl in length and Feet in tividth <br /> FEES <br /> Encroachment Permit base fee . . . . . . . . . . . S40.00 <br /> Field.Inspection <br /> Drivewayw/or w,�o pipe . . . . . . . 550.00 C] Paved Frontage . . . . . . . . .$50.00 + .25/ft <br /> ❑ Driveway w/Box Culvert . . . . . . SS0.00 C1Curb, Gutter, Sidewalk . . 350.00 + .50/ft <br />