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THE APPLICANT HEREBY CERTIFIES: <br />1. That he / she has read all the provisic if this application, and that the descriptio "ricluded 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 -War at the above indicated site without a valid San Joaquin County Encroachment Permit; and <br />6. That if pJI iss,' n is granted as requested, he agrees to do the work described in accordance with all terms, <br />Gond ti�4id "astrictions of this and any attached sheet, included as general or special provisions. <br />Signature of Applicant - Title Date <br />FIELD INSPECTOR COMMENTS <br />»»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««< <br />1. DRIVEWAY: None Dirt Gravel Aggregate Base Paved(Poor) Paved(Good) <br />2. SLOPING: Away from Pavem nt Towards. Paveme _ Flat <br />3. PIPES: None Existing - Type % Z <br />Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br />Attachment to neighbor's pipe: Yes N� <br />4. HEADWALL: Yes NoQ, <br />5. ASPHALT CONCRETE DIKE: Yes No -y- <br />6. BARRIERS alon fight -of -Way - <br />7. DITCH Yes No If Yes: V Style_ 2 Pointe Other Width, Depth_ <br />»»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br />1. DRIVEWAY: SFR COMMERCIAL AGRIC�TURE INDUSTRIAL <br />PAVED with 2" Min. Dept A.C. over " Min Depth 3/4" A.B. <br />or <br />4" Min. Depth Portland Cement Concrete. <br />Notes: <br />2. PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipe /Z Inch <br />To be connected to any adjacent driveway pipe Yes No <br />DRAINAGE INLET REQUIRED Yes No ,2 <br />Total Length: (with proposed) Total Number of Storm Drain Inlets <br />Notes: <br />3. HEADWALL Yes No� -- <br />4.. PAVED FRONTAGE: PAVED with'`V " Min. Depth A.C. over " Min. Depth 3/4" A.B. <br />measuring Feet in length and Feet in width <br />FEES <br />IEW611ichment Permit base fee .....$40.00 <br />field Inspection <br />Driveway w/ or w/o pipe .....$50.00 Q Paved Frontage ........ $50.00 + .25/ft <br />0 Driveway w/ Box Culvert .... $80.00 Curb, Gutter, Sidewalk ...$50.00 + .50/ft <br />