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THE APPLICE1IN-F HEREB"_CERTIFIES: <br /> 1.That he/she ha;read all the pmvisiv,15 of this application,and that the descriptions inUuded above arc 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 be/she will assume full resporisibility for all liability for personal injury or daniage to property which may arise out of <br /> the work described 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 of such liability is made arLzinst the County of San Joaquin or any department,offival or employee <br /> thereof;he shall defend,indemnify and hold them and each of them harmless for z-uch claim;and <br /> S.T bat no work shall be perforated by the applicant and/or any representatives of the applicant in the County Right-of-Way at <br /> the above indicated site without 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,conditions and <br /> restrictions of this and any attached sheet,included as general or special 111 provisions. <br /> Signature of Applicant -title Date <br /> FIELD INSPECTOR COINENIENTS <br /> »»»»»»»»» EXISTING CONDITIONS «««««««««< <br /> 1. DRIVEWAY: None Dirt . � Gravel Aggregate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOPING: Away from Pavement Towards Pavement Flat <br /> 3. PIPES: None 0� E:cisting -Type <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No� <br /> 4. HEAD'W'ALL: Yes No�_ 5. ASPHALT CONCRETE DIKE: Yes No <br /> 6. BARRIERS along Right -Of-Way <br /> 7. DITCH Yes No If Yes: V Style 2 Point_Other Width Depth <br /> »»»»»»»»»» PERMIT REQUIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR COM'Y1ERCIAL--�.�— AGRICULTURE INDUSTRIAL <br /> PAVED with "Min.Depth A.0 over "Na. 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 adjacznt driveway pipe Yes No ' <br /> DRAINAGE INLET 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 NILL Depth A.0 over "Min.Depth 3/4" A.B. <br /> measuring Fejt in leugth and Feet in width <br /> FEES <br /> Encroachment Permit base fee . . . . . . . . . . . S40.00 <br /> Field Inspection <br /> I?riveway w/or w/o pipe . . . . . . . $50.00 C1 Paved Frontage . . . . . . . . .$50.00 + .25/ft <br /> ❑ Driveway w/Bos Culvert . . . . . . SS0.00 ❑ Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />