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THE "PLICANT HEREBY CERTIFIES: <br /> 'chat lie / she has read all the provisionF this application, and that the description -�cluded 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 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 /> D to <br /> S' nature o Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> >>>>>>>>>>>>>>>>>>>>>>>>>EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt o Gravel Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement Towards Pavement Flat <br /> PIPES: Non Existing -Type <br /> Other pipes in neighborhood: Yes No pproaches Cross Drain Size <br /> Attachment to n ighbor's pipe: Yes No <br /> HEADWALL: Yes N <br /> ASPHALT CONCRETE DIKE: Yes Nc <br /> BARRIERS along Right-of-Way <br /> DITCH Yes NoC>4 If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> »»»»»»»»»»»»>P E R M IT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFIt COMMERCIAL AGRICU URE 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 /> rtes: <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 ��ameier of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes <br /> DRAINAGE INLET REQUIRED Yes No <br /> ncf <br /> Total Length: (with propose(T) Total Num er of Storm Drain Inlets <br /> rtes: <br /> HEADWALL Yes Na <br /> PAVED FRONTAGE: PAVED witf Min. Depth A.C. over_" Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feel in width <br /> FEES <br /> -icroachment Permit base fee . . . . .$40.00 <br /> eld Inspection <br /> Driveway w/or w/o pipe . . . . .550.00 0 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S80.00 a Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />