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THE APPLICANT HEREBY CERTIFIES:_ <br />1. That he / she has read all the provisions his application, and that the descriptions luded 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 Date <br />FIELD INSPECTOR COMMENTS <br />»»»»»»»»»»»»> EXISTI NG CONDITI ONS «««««««««««< <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 Existing -Type <br />Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br />Attachment to neighbor's pipe: Yes NoI2:!�_ <br />4. HEADWALL: Yes NqZ' <br />5. ASPHALT CONCRETE DIKE: Yes y Na <br />6. BARRIERS along Right -of -Way <br />7. DITCH Yes No,,x If Yes: V Style_ 2 Point_ Other Width_ Depth <br />»»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br />1. DRIVEWAY: SFR COMMERCIAL AGRICU TURE INDUSTRIAL <br />PAVED with 2" Min. Depth A.C. over Min Depth 314" A.B. <br />or <br />i 4" Min. Depth Portland Cement Concrete. <br />Notes: <br />2. PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipe Inch <br />To be connected to any adjacent driveway pipe Yes No� <br />DRAINAGE INLET REQUIRED Yes Nop <br />Total Length: (with proposed) Total Nu ber of Storm Drain Inlets <br />Notes: <br />3. HEADWALL Yes Noz- <br />4. PAVED FRONTAGE: PAVED with _Min. Depth A.C. 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 />Field Inspection <br />11771 Driveway w/ or w/o pipe .....$50.00 Paved Frontage ........ $50.00 + .25/ft <br />DQ <br />Driveway w/ Box Culvert .... $80.00 0 Curb, Gutter, Sidewalk ...$50.00 + .50/ft <br />