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THE APPLICANT HEREBY CERTIFIES: <br />1. That he / she has read all the pro.vis of this application, that the descript: _ included above are correct <br />to the best of 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 dmage to property which may <br />arise out of the work described above, or which may arise out of his / her failure to do the work provided for <br />herein; and <br />4. That in the event any claim of such liability is made against the County of San Joaquin or any department, <br />official or employee thereof, he shall defend, indemnify and hold them. and each of them harmless for such claim; <br />and <br />5. That no work shall be performed by the applicant and / or any representatives of the applicant in the County <br />Right -of -Way at 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, <br />conditions and restrictions of this and any attached sheet, included as general or special provisions. <br />Signature of Applicant - Title <br />Date <br />FIELD INSPECTOR COMMENTS <br />»»»»»>.»»»»»»»EXISTING CONDITIONS«««««««««««< <br />1. DRIVEWAY: <br />None Dirt Gravel Aggregate Base Paved(Poor) Paved (Good)__..,_ <br />2. SLOPING: <br />Away from Pavement Towards Pavement Flat <br />3. PIPES: <br />None Existing - Type // k <br />Other pipes in neighborhood: Yes No Approaches k Cross Drain Size !� <br />Attachment tc�reighbor's pipe: Yes Nom <br />4. HEADWALL: <br />Yes Na <br />5. ASPHALT CONCRETE DIKE: Yes NoZ <br />6. BARRIERS <br />along Ri ht -of -Way <br />7. DITCH <br />Yes Y No If Yes: V Style_, 2 Point Other Width,Z Depth <br />»»»»»»»»»»»»>PER IT REQUIREMENTS ««««««««««««< <br />1. DRIVEWAY: <br />SFR COMMERCIAL AGRICULTURE INDUSTRIAL <br />PAVED with 2" Min. Depth A.C. over,_,," Min Depth 3/4" A.B. <br />or <br />4" Min. Depth Portland Cement Concrete. <br />Notes: <br />2. PIPES: <br />Length of pipe Required: See Form R-1.7., Note 4 Diameter of Pipe /2 Inch <br />To be connected to any adjacent driveway pipe Yes No_,2L <br />DRAINAGE INLET REQUIRED Yes No /I <br />Total Length: (with proposed) Total Number of Storm Drain Inlets <br />Notes: <br />3. HEADWALL Yes No—t�'— <br />' Min. Depth A.C. over " Min. Depth 3/4" A.B. <br />4. PAVED FRONTAGE: <br />PAVED wit <br />measuring Feet in length and Feet in width <br />FEES <br />Encroachment Permit base fee .....$40.00 <br />Field jnspection <br />Driveway <br />w/ or w/o pipe .....$50.00 0 Paved Frontage ........ $50.00 + .25/ft <br />Driveway w/ Box Culvert .... $80.00 Curb, Gutter, Sidewalk ...$50.00 + .50/ft <br />