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THE APPLICANT HEREBY CERTIFIES: <br />1. That he / she has read all the provisi of this application, and that the descriptir— included above are correct <br />to the best of his / her knowledge; ano <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, If permission is grante uested, he agrees to do the work described in accordance with all terms, <br />conditi and s f this a d any attached sheet, included as general or special provisions. <br />Signatui6 of Applicant - Title Date <br />FIELD INSPECTOR COMMENTS - <br />1. DRIVEWAY: <br />»»»»»»»»»»»»>EXISTING CONDITIONS««««««< ««««< <br />None Dirt Gravel? Aggregate Base Paved( <br />2. SLOPING: <br />oo� Paved(Good) <br />Away from Pavement To rds pavement Flat <br />3. PIPES: <br />None Existing - Type / <br />Other pipes in neighborhood: Yes I No Approaches Cross Drain Size_,�� <br />Attachment to neighbor's pipe: Yes/V No <br />4. HEADWALL: <br />Yes No% <br />5. ASPHALT CONCRETE DIKE: Yes No� <br />6. BARRIERS <br />along Right -of -Way ----' <br />7. DITCH <br />Ye sNo If Yes: V Style_ 2 Point Other Widths Depth_ <br />»»»»»> »»»»»»>PERMIT REQUIREMENTS««««««««««««< <br />1. DRIVEWAY: <br />SFFiCOMMERCIAL 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-17, Note 4 Diameter of Pipe 12— Inch <br />To be connected to any adjacent driveway pipe Yes NO- <br />DRAINAGE INLET REQUIRED Yes No <br />Total Length: (with proposed) Total Number of Storm Drain Inlets <br />Notes: <br />3. HEADWALL <br />Yes No <br />4. PAVED FRONTAGE:. _ PAVE 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 nspection <br />Driveway <br />w/ or w/o pipe ......$50.00 Q Paved Frontage ........ $50.00 + .25/ft <br />Driveway w/ Box Culvert .... $80.00. Curb, Gutter, Sidewalk ...$50.00 + .50/ft <br />