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THE APPLICANT HEREBY,CERTIFIES: <br /> 1.That he/she has read all the prov.' y of this application,and that the descriptions ►ded 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 department,official or employee <br /> thereo&he shall defend,mdenmify and hold them and each ofthem harmless for such claim;and <br /> 5.That no work shall be performed by the applicant and/or any representatives of the applicant in the County Right-oPWay 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 Dirt Gravel Aggregate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOPING: Away from Pavement_D 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: Yes No <br /> 4. HEADWALL: Yes No 1�— 5. ASPHALT CONCRETE DIKE: Yes N4/f <br /> 6. BARRIERS along Right -Of-Way- <br /> 7. DITCH Yes_N� If Yes: V Style 2 Point—Other Width Depth <br /> »»»»»»»»»» PERM[IT REQUIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR COlvll'vIERCIAL AGRIC TORE INDUSTRIAL <br /> PAVED with 2.- " Min.Depth A.0 over "?vlim Depth 3/4" A.B. <br /> ROCKED with —" ,Min. Depth 3/4" A.B. <br /> Notes <br /> Lich <br /> 2. PIPES: Length of Pipe Required: Ft. and Diameter of Pipe <br /> To be connected to any adjacent driveway pipe Yes N Y / <br /> DRAINAGE INLET REQUIRED YES N� <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with `-TJ " Min Depth A•C over " titin. Depth 3/4" A.B. <br /> mcasu ng Feet in length and Feet in width <br /> FEES <br /> Encroachment Permit base fee . . . . . . . . . . . $40.00 <br /> Field Inspection ❑ Paved Frontage . . . . . . . . .$50.00+ .251ft <br /> 46 Driveway w/or w/o pipe . . . . . . . $50.00 ❑ Curb, Gutter, Sidewalk . . .$50.00+ .50!ft <br /> ❑ Driveway w!Box Culvert . . . . . . $50.00 <br />