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THCANT HEREBY CERTIFIES- <br /> .i- <br /> ERTIFIES.i hat lie / she has read all the provisions . this application, and that the description- :luded 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 o�•ner, 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 /> condUio4s.and restrictions of this and any attached sheet, included as general or special provisions. <br /> Signature of A ant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> >>>>>>>>>>>>>>>>>>>>>>>>>EYJSTING CO N D ITI ONS«««««««««««< <br /> DRIVEWAY: None Dirt GravelAggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement To ards Pavement Flat <br /> PIPES: None Existing -Type /Z <br /> . <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain Size <br /> AttachmeZg: <br /> ghbor's pipe: Yes N� <br /> HEADWALL: Yes <br /> ASPHALT CONCRETE DIKE: Yes N , <br /> BARRIERS along Right-of-Way <br /> DITCH Yes N If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> »»»»»»»»»»»»>P ER M IT R EQ U I REM ENTS««««««««««««< <br /> DRIVEWAY: SFR (-),/ COMMERCIAL AGRICU TURE INDUSTRIAL <br /> PAVwith 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 D' meter of Pipe Inch <br /> To be connected to any adjacent driveway pipe es N <br /> DRAINAGE INLET REQUIRED Yes N <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> rtes: <br /> HEADWALL Yes— N <br /> PAVED FRONTAGE: p V withMin. Depth A.C. over " Min. Depth 314"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> -icroachment Permit base fee . . . . .$40.00 <br /> eld A nspection <br /> Driveway w/or w/o pipe . . . . .$50.00 0 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S60.00 = Curb, Gutter, Sidewalk . . .$50.00 + .50/ft <br />