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­�11 J nZr%CD) l.tt( I IF'Itb: <br /> 2t he / she hes read all the provis; ns of this application, and that the descrip''"is included above are correct <br /> to the best of his / her knowledoe; a, <br /> That he /she is the owner of the respective property, or is qualified to represent the o.vner, 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 /> Signature of Applicant -Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»» »»» ««««««««««« <br /> EXISTING CONDITIONS < <br /> DRIVEWAY: None Dirt; Gravel Aggregate Base Paved(Poor) Paved(Good <br /> SLOPING: Away from Pavemen41 — Towards Pavement Flat ) <br /> PIPES: None Existing ype <br /> Other pipes in neighborhood: Yes No :X Approaches Cross Drain Size <br /> _ Attachment to neighbor's pipe: Yes No -k' <br /> HEADWALL: Yes No? <br /> ASPHALT CONCRETE DIKE: 11—,Yes No� <br /> BARRIERS along Right-of-Vj/ay <br /> DITCH Yes Nd If Yes: V Style— 2 Point_ Other Width_ Depth <br /> »»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR COMMERCIAL AGRICULTURE INDUSTRIAL <br /> PAVED with 2" Min. Depth A.C. over L " 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 <br /> To be connected to any adjacent driveway pipe Yes N eter of Pipe Inch <br /> DRAINAGE INLET REQUIRED Yes No,�/ �D <br /> - <br /> Total Length: (with proposed) Total N mu ber of Storm Drain Inlets <br /> .tes: <br /> HEADWALL Yes No� <br /> PAVED FRONTAGE: PAVED with �-' - N,in. Depth A.C. over ' Min. Depth 3/4"A.B. <br /> measu�ng Feet in length and Feet in width <br /> FEES <br /> ;roachment Permit base fee . . . . .54.00 <br /> td Inspection <br /> Driveway w/or w/o pipe . . . . .Ss.^ 00 <br /> "` � Paved Frontage . . . . . . . . 550.00 + .2511,1 <br /> Driveway w/ Box Culvert . . . . SS0.00 o Curb, Gutter, Sidewalk . . .$50.00 + .50/ft <br />