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i"HC . r-�PLICANT HEREBY CERTIFIES.: <br /> `;at lie / she has read all the provisions this application, and that the description :!uded 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 prranted as requested, he agrees to do the work described in accordance with all terms, <br /> conditions and restri ions of this and any attached eet, included as gen/e`r or sp-? cial provisions. <br /> _ _ L <br /> — /.,*" <br /> - , <br /> ('�/-,,- <br /> Signa of A i nt-Title Date <br /> T <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»>»»»EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Gravel Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement Towards Pavement Flat <br /> PIPES: None Existing -Type 12- Z if <br /> Other pipes in neighborhood: Yes X No Approaches ix Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No/�_ <br /> HEADWALL: Yes NoX. <br /> ASPHALT CONCRETE DIKE: Yes Nom <br /> BARRIERS along Right-of-Way <br /> DITCH Yes No If Yes: V Style_ 2 Point : Other Width? Depth <br /> »»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR,/Z, COMMERCIAL AGRIC TURE 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 /> otos: <br /> 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,-X—/ <br /> DRAINAGE INLET REQUIRED Yes Nq�— <br /> Nu <br /> Total Length: (with proposed) Total mber of Storm Drain inlets <br /> rtes: <br /> HEADWALL Yes N0-2, —� <br /> 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 /> ---oachment Permit base fee . . . . .540.00 <br /> _i� Inspection <br /> Driveway w/or w/o pipe . . . . .550.00 Paved Frontage . . . . . . . . $50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S80.00 Curb, Gutter, Sidewalk . . .$50.00 + .50/ft <br />