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�-'E APPLICANT HEREBY CERTIFIES _ <br /> That he /she has read all the provisions u, this application, and that the descriptions included above are correct <br /> to the best of his/ her knowledge: and <br /> That he/she is the owner of the respective property, or is qualified to represent the owner, and <br /> 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 /> 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 /> 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 /> That, if permission is granted as requested, he agrees to do the work described in accordance with all terms, <br /> ACO and trictions of this and any attached sheet, included as general or special provisions. <br /> z P V <br /> Signature o Applicant - Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt <br /> SLOPING: Gravel Aggregate Base Paved(Poor) Paved(Good)� <br /> Away from Pavement Towards Pavement Flat <br /> PIPES: None Existing - Type <br /> Other ipes in neighborhood: Yes No <br /> Attachment to neighbors Approaches Cross Drain Size <br /> HEADWALL: Yes No pipe: Yes No <br /> ASPHALT CONCRETE DIKE: Yes No <br /> BARRIERS along Right-of-Way <br /> DITCH Yes Nor If Yes: V Style <br /> _ 2 Point_ Other Width_ Depth <br /> »» """>""»»»»>P E R M I T REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR'i3--1` COMMERCIAL'->( AGRICULTURE INDUSTRIAL <br /> PAV9with 2" Min. Depth A.C. over " Min Depth 3/4" A.B. <br /> or <br /> 4" Min. Depth Portland Cement Concrete. <br /> otes: SES 1JE� Tom, <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 <br /> To be connected to any adjacent drivewaypipe Diameter of Pipe <br /> PP� Yes Inch DRAINAGE INLET REQUIRED Na <br /> Yes No �, <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> es: -- <br /> HEADWALL Yes Nox <br /> PAVED FRONTAGE: PAVED with " Min. De th A.C. over <br /> P' —6' ' Min. Depth 3,'4" A.B. <br /> measuring'3Sz'__Q=Feet in length and <br /> 0" Feet in width <br /> croacthment Permit base fee . . . . . <br /> EES <br /> .54000 <br />;IJ Inspe�ion ��9 0?� <br /> Driveway w/ or wio pipe . . . . .S <br /> ^ II .'a\•ed `_rolita e CCl1 �nn + .� <br /> Dn•:eway wi Box Cul•.�e,; . . . . 580.uv <br /> L� Curb, G,-,,!er, Side'.va;k . . .550.00 + <br />