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'THE APPLICANT HEREF-' CERTIFIES: <br />1. That he /she has read all the pro,, m of this application, and that the descriptions uded 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 />thereof, 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 of the applicant in the County Ri&-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 <br />FIELD INSPECTOR COMMENTS <br />Date <br />»»»»»»»»»» )EXISTING CONDITIONS «««««««««< <br />1. DRIVEWAY: None Dirt `� Gravel Aggregate Base Paved (Poor) Paved (Good)_ <br />2. SLOPING:way from Pavement ( 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 N 5. ASPHALT CONCRETE DIKE: Yes N� <br />6. BARRIERS along Right -Of- <br />7. DITCH Yes N&rX_ If Yes: V Style 2 Point _ Other Width Depth <br />>>>>>>>>>>>>>>>>>>>>PERNIIT REQUIREMENTS ««««<�««««< <br />i. DRIVEWAY: SFR C>>>>>>>>>>>>>>>>>>>>> COMN ERCIALAGRIC - TURE INDUSTRIAL <br />PAVED with 'Z— " 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 <br />DRAINAGE INLET REQUIRED YES NFO <br />Total Length:(with proposed) Total Number of Storm Drain Inlets <br />Notes <br />3. HEADWALL Yes hT� _ <br />4. PAVED FRONTAGE: PAVED with " Min. Depth A.0 over "Min. Depth 3,`4" A.B. <br />measuring Feet in length and Feet in width <br />FEES <br />Encroachment Permit base fee ........... $40.00 <br />Fieldpspection <br />Q�- Driveway w/ or w/o pipe ....... $50.00 <br />0 Driveway w/ Box Culvert ...... $80.00 <br />❑ Paved Frontage .........$50.00 + .25/ft <br />❑ Curb, Gutter, Sidewalk ...$50.00 + .50/ft <br />