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THE APPLICAIN i HEREBY CERTIFIES: <br /> 1.That he/she has read all the pror—-m of this application,and that the descriptions"luded above 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 personal injury or damage 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 against the County of San Joaquin or any departmes t,official or employee <br /> thane t he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5.That no work shall be performed by the applicant and/or any representatives ofthe 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,ifpermission is granted as requested,he agrees to do the work described in accordance with all terms,conditions and <br /> restrictions ofthis and any attached sheet,included as general or special 111 provisions. <br /> Signature of Applicant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»» EXISTING CONDITIONS «««««««««< <br /> 1. DRIVEWAY: None Y�—Dirt Gravel Aggregate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOPING: Away from Pavement _ Towards Pavement Flat <br /> 3. PIPES: None Existing-Type <br /> Other pipes in neighborhood: Yes IV No Approaches ,Cross Drain Size 1 i� <br /> Attachment to neighbor's pipe: Yes No <br /> 4. HEADWALL: Yes No 5. ASPHALT CONCRETE DIKE: Yes No <br /> 6. BARRIERS along Right-Of- <br /> 7. DITCH Ye.�No If Yes: V Style 2 Point [-�>( Other Width Z Depth--2, <br /> »»»»»»»»»» PERMIT RE UIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR CGINS ERCIAL AGRICULTURE INDUSTRIAL <br /> PAVED with 2-- "Min. Depth A.0 over O "Min. Depth 3/4" A.B. <br /> ROCKED with "Min. Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: 1� `F Ft and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes No <br /> DRAINAGE INLET REQURED YES NO V <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No I)(- _ <br /> 4. PAVED FRONTAGE: PAVED with " :vain Depth aC over ";Vtin Depth 3/4" A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> Encroachment Permit base fee . . . . . . . . . . . $40.00 <br /> Field Imipection <br /> ,t Driveway w/or w/o pipe . . . . . . . $50.00 ❑ Paved Frontage . . . . . . . . .$50.00 + .25/ft <br /> 0 Driveway w/Box Culvert . . . . . . $80.00 0 Curb, Gutter, Sidewalk . . .$50.00+ .i0/ft <br />