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THE APPLICAi�'T HEREBY ERTIFTES: <br /> 1.That he/she hn:read all the protiisions of this application,and that the descriptions included above arc correct to the best of <br /> his/her knowledge,and <br /> 2.That he/she is the owner of the respccdve property.or is qualified to represeat the owner.and <br /> 3.That bel she will assume full respotuibility for all Liability for personal injury or dantage to property which may arise out of <br /> the work dacribcd above,or which may arise out of his/her failure to do the work provided for herein;and <br /> 4.That in the event any claim ofsvch liability is made a2 inst the County of San Joaquin or any departru mt,offidal or employee <br /> thaco&he shall defend,i:.dc .ify and hold th.W and cath of theta h-=1csz for such claim;and <br /> S.That no Nvork shall be performed,by the applicant and/or any represeatatives of the applicant in the County Right-of-Way ai <br /> the above indicated site Nvi hcwt a valid San Joaquin County Encroacl-zzent PGzniti and <br /> 6.Thar,if permission is granted as'requesLed,he agrees to do the work descriibed in accordance with all terms,conditions and <br /> res•t;•ictions of this and any attached sheet, included as g neral or special 111 provisi-m. <br /> Signature of Applicant -Title Date <br /> FIELD INSPECTOR CO'.,Nf1tENTS <br /> »»>»»»»»»»> EXISTn., G CO�t'DITIONS «««««««««< <br /> 1. DRIVEWAY: None Dirt Gravel Aggregate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOMG: Away from Pavement 0_ Towards Pavement Flat <br /> 3. PIPES: None E:zsting -Type <br /> Other pipes in neighborhood: Yes C/ No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No CX <br /> 4. HEADWALL- - fr <br /> 'es o�_ 5. ASPI-ULLT CONCRETE DIKE: Yes No <br /> 16. BARRIERS along Right -Of-Way <br /> 7. DITCH Yes (-No If Yes: V Style 2 Point Other Width_' Depth f' <br /> »»»»»»»»»» PERMIT REQUIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR X_ CO: RCLAL AGRICL TUBE INDUSTRIAL <br /> PAVED with Min. Depth A.0 over "Min. Depth 3/4" A.B. <br /> ROCKED with " Min. 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 ce <br /> DRAINAGE E IL.ET REQUMED YES NO <br /> Total Length: (with proposed) Total dumber of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No_ _ <br /> 4. PAVED FRONTAGE: PAVED with ..�-- " Min. Depth A.0 over " Min. Depth 3/4" A.B. <br /> mcasurins,5' Fe~l in length and Feet in width <br /> FEES <br /> Pncroachment Permit base fee . . . . . . . . . . . S40.00 <br /> old Inspection <br /> C] Paves Frontage . . . . . . . . .$50.00 + .25/ft <br /> Driveway w/ or,.v!o pipe . . . . . . . $50.00 CD . Curb, Gutter, Sidewall: . . .550.00 + .50/ft <br /> C1 Driveway w/Boa Culvert . . . . . . S80.00 <br />