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THE PPPLICANT HEREBY CERTIFIES: <br /> 'chat he /she has read all the provisior this application, and that the descriptior—ncluded 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- Katabove indicated site without a valid San Joaquin County Encroachment Permit; and <br /> That, if ranted as requested, he agrees to do the work described in accordance with all terms, <br /> conditio ions of his and any attached sheet, included as general or special provisions. <br /> Sig re of Applican -Title Date <br /> i <br /> i <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXI TING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Gravel_►Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away fro Pavement Towards Pavement Flat <br /> PIPES:. None Existing -Type <br /> Other pipes in neighborhood: Yes No_' Approaches Cross Drain Size <br /> _ Attachment to net hbor's pipe: Yes No <br /> HEADWALL: Yes No c co <br /> ASPHALT CONCRETE DIKE: Yes No -� .,ut <br /> BARRIERS along Right-of-W y `-- <br /> DITCH Yes No if Yes: V Style_ 2 Point_ Other)Width Depth <br /> r <br /> »»»»»» >>>>>>>>>>>>PERMIT REQUIREMENTS««««<<<%t <br /> DRIVEWAY: SFR COMMERCIAL AGRICU TURE INDUSTRIAL <br /> PAVED with 2" Min. Depth A.C. over " Min Depth 3/4" A.B. c� < <br /> or C c_ <br /> 4" Min. Depth Portland Cement Concrete. <br /> rtes: <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Di eter of Pipe�nch <br /> To be connected to any adjacent driveway pipe s No <br /> DRAINAGE INLET REQUIRED Yes No� <br /> Total Length: (with proposed) Total Number of Storm Drain inlets <br /> )tes: <br /> HEADWALL Yes NoQ <br /> PAVED FRONTAGE: PAVED wit Min. Depth A.C. over " Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> -croachment Permit base fee.. . . . .$40.00 <br /> eld Inspection <br /> Driveway w/or w/o pipe . . . . .$50.00 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S80.00 0 Curb, Gutter, Sidewalk . . .S50.00 + .50/ft <br />