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THE APPLICANT HEREBY .'RTInES: <br /> 1.That he/she has read all the pmv7aions of this application,and that the descriptions included above arc correct to the best of <br /> hi;/her knowledge;and <br /> 2.That he/she is the owner of the respective property.or is qualiucd to mpracat the owner;and <br /> 3.That bel she will assume full responsibility for all liability for personal injury or daniage to property which may arise out of <br /> the work described above,or which may&rise out of his/her failure to do the work provided for herein; and <br /> 4.That in the event anv claim of iuc:h liability is made ap iast the County of San Joaquin or any department,official or employee <br /> thereof;he shall dci'ad,indcuaZy and hold th=and ca;h of them h----Tcs for such claim;and <br /> 5.That no work shah be performed by the applicnct and/or any represeirraiives of the applicant in the County Right-of-Way at <br /> the above indicat--d site tivithout a va!id Sim Joaquin County Encroaclunczt Pcmit;find <br /> ti.That, if permission is granted as requested,he agrees to do the work de crIed in accordance with all terms,conditions and <br /> restictions o£thi- and any attached sheet, i.:cluded as gmcral or special 111 pnovisions. <br /> Signature of Applicant -Title bate <br /> FIELD I-'SPECTOR COIni IENTS <br /> »»»»»»»»»» EXISM.,'G CONDITIONS «««««««««< <br /> 1. DRIVEWAY: None D( Dirt Graxel Agg�-egate Base Paved (Poor) Paved (Good)_ <br /> 2. SLOPING: Away from Pavement 0< Towards Pavement Flat <br /> 3. PIPES: None Existing - Typeti <br /> Other pipes in neighborhood: Yes No Approaches�Cross Drain Size /z, <br /> Attachment to neighbor's pipe: Yes No-V <br /> 14. HEADWAILL: Yes No 5. ASPI:-LkLT CONCRETE DIKE: Yes <br /> 6. BARRIERS along Right -Of-Way <br /> 7. DITCH YesIti'o If Yes: V Style 2 Point Other Width Depth 2 r <br /> »»»»»»»»»» PERMIT REQUIREMENTS «««««««««< <br /> 1. DRIVEWAY: SFR ' _ CONINCIYERCLAI, AGPJTUBE IINDUSTRIAL <br /> PAVED tivith 7i "Na. Depth A.0 over 7L " Min. Depth 3/4" A.B. <br /> ROCKED with " Ilyfi.n. Depth 3/4" A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: <br /> +41e-, <br /> Ft. and Diameter of Pipe _Inch <br /> To be connected to any adjacenay pipe Yes No <br /> DRAINAGE INLET REQUIRED YES NO o>_ <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with �" Miu. Depth A.0 over "Mim Depth 3/4" A.B. <br /> mcasuri.ng FetA in length and Feet in tividth <br /> FEES <br /> Encroachmeni Permit base tee . . . . . . . . . . . S40.00 <br /> Field Inspection ❑ paved Frontage . . . . . . . . .550.00 + .25/ft <br /> Driveway w/or w/o pipe . . . . . . . S50.00 ❑ Curb, Gutter, Sidewall: . . .550.00 + .50/ft <br /> 0 Driveway w/Box Culvert . . . . . . SS0.00 <br />