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1. That he/she has read all the provisions of this application,and that the descriptions included above are correct to the best of histhcc <br /> 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 the work <br /> described above,or which may arise out of his/her failure to do the work provided 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 /> thereof,he shall defend,indemnify and hold them and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representatives of the applicant in the County Right-of-Way at the above <br /> indicated site with 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 /> restri ' ns of this and any attached t,included as general or special III provisions. <br /> Signature of Applicant–Title ate <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 �— Towards Pavement Flat <br /> 3. PIPES: None W Existing– <br /> Other pipes in neighborhood: Yes X, No 40 <br /> & Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No KL <br /> 4. HEADWALL: Yes No it <br /> 5. ASPHALT CONCRETE DIKE: Yes No <br /> 6. BARRIERS along Right-of-Way <br /> 7. DITCH Yes b"-No If Yes: V Style bL 2 Point Other Width Depth <br /> »»»»»»»»»»»»»»»PERMITREQUIREMENTS««««««««««««««« <br /> 1. DRIVEWAY: SFR Z- COMMERCIAL 4t AGRICULTURE INDUSTRIAL <br /> PAVED with "Min.Depth A.0 over "Min.Depth 3/4"A.B. <br /> Rocked with "min..Depth%"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 IP <br /> DRAINAGE INLET REQUIRED Yes No V— <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.0 over "Mina Depth 3/a"A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES_ <br /> Encroachment Permit base fee .................. 85� <br /> Field Inspection 6 <br /> gtr-Driveway w/or w/o pipe .............$ f Q Paved Frontage..............$80.00+ .37/ft <br /> p Driveway w/Box Culvert ............$125.00 c3 Curb, Gutter, Sidewalk.....$80.00 + .78/ft <br /> C:\My D---itsT—and Templatellhiv—y pmt application(reverse side).d- <br />