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i;HE f--pLICANT HEREBY CERTIFIES!,. <br /> ,-nat lie / she has read all the provisions this application, and that the descdptior -.luded 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 /> conditions and restrictions of this and any attached sheet, included as general or special provisions. <br /> t � <br /> Ito <br /> Signature of Applicant -Title Date <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 r� <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size/z <br /> Attachment to neighbor's pipe: Yes N <br /> HEADWALL: Yes No� <br /> ASPHALT CONCRETE DIKE: Yes NoL>L <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 COMMERCIAL AGRICU 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 /> PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipe �2— Inch <br /> To be connected to any adjacent driveway pipe Yes NoA-" <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total Nu ber of Storm Drain Inlets <br /> es: <br /> HEADWALL Yes No�4 <br /> PAVED FRONTAGE: PAVED wi "'Min. A.C. over ' Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> oachrnent Permit base fee. . . . . .$40.00 <br /> d Inspection <br /> Driveway w/or w/o pipe . . . . .$50.00 0 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . 580.00 Curb, Gutter, Sidewalk . . .S50.00 + .50/fi <br />