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E r'PLICANT HEREBY <br /> CERTIFIES- <br /> "gat he /she has read all the provisions _ this application, and that the description-, auded above are correct <br /> o the best of his/her knowledge; and <br /> hat 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 /> eonditio sand restrict'ons o 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 /> DRIVEWAY: None DirtZXGravel Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement Towards Pavement O _ Flat <br /> PIPES: None, Existing -Type <br /> Other pipes in neighborhood: Yes Nog Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes NoA <br /> HEADWALL: Yes t-oX <br /> ASPHALT CONCRETE DIKE:" Yes— 0 <br /> BARRIERS along Right-of-Way <br /> DITCH Yes N@� If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> »»»»»»»»»»\»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SF� COMMERCIAL AGRICU TURE INDUSTRIAL <br /> PA ED with 2" Min. Depth A.C. over " Min Depth 3/4"A.B. <br /> or <br /> 4" Min. Depth Portland Cement Concrete. <br /> yes. <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipnch <br /> To be connected to any adjacent driveway pipe Yes N <br /> DRAINAGE INLET REQUIRED Yes <br /> Total Length: (with proposed) Total Num er of Storm Drain Inlets <br /> `es: <br /> HEADWALL Yes <br /> PAVED FRONTAGE: AVED wit " 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 /> = d Inspection <br /> Driveway w/or w/o pipe . . . . .550.00 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . $80.00 Curb. Gutter, Sidewalk . . .$50.00 + .50/111 <br />