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'i HE : .`'PLICANT HEREBY CERTIFIES: <br /> that he / she has read all the provisions his application, and that the descriptionsluded 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 /> Signiture of Applicant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Gra el Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement r. Towar s�avement Flat <br /> PIPES: None Existing -Type <br /> Other pipes in neighborhood: Yds_X No ApproachesA Cross Drain Size <br /> _ Attachment to nei hbor's pipe: Yes NoX <br /> HEADWALL: Yes No 11 <br /> ASPHALT CONCRETE DIKE: Yes No_ <br /> BARRIERS along Right-of-Way — <br /> DITCH YesLX No If Yes: V Style_ 2 Point Other Width_ Depth <br /> »»»»»> >> »»»»»PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR ;COMMERCIAL AGRICU-TURE INDUSTRIAL <br /> PAVE th 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 Diameter of Pipe.,,-, In nch <br /> To be connected to any adjacent drivewaypipe Y N 16 <br /> DRAINAGE INLET REQUIRED Yes No� <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> rtes: <br /> HEADWALL Yes No t` <br /> PAVED FRONTAGE: PAVED with Min. Depth A.C. over ' Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> -icroachment Permit base fee . . . . .$40.00 <br /> -2Id nspection <br /> Driveway w/or w/o pipe . . . . .$50.00 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . SS0.00 Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />