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THE c`•..""LICANT HEREBY CERTIFIES: <br /> this application, and that the description-- eluded above are correct <br /> That he /she has read all the provisions <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 /> condition and restricti of this and any attached sheet, included as general or special provisions. <br /> S na ure o Applicant- le Date f' <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXISTIN G CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Gravex0ards <br /> Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavem nt Pavement Flat <br /> PIPES: Non #pipiS <br /> Existing-Type roaches Cross Drain Size <br /> Othein neighborhood: Yes No pp <br /> Attachment to n rghbor's pipe: Yes No <br /> HEADWALL: Yes �. <br /> 4 <br /> ASPHALT CONCRETE DIKE: Yes No <br /> BARRIERS along Right-of-Way <br /> DITCH Yes Nd� If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> >>>»»»»»»»»»»»PERMIT REQUIREMENTS <br /> ««««««««««««< <br /> DRIVEWAY: SFR COMMERCIAL AGRICU TURE INDUSTRIAL <br /> PAV�6 h 2" Min. Depth A.C. over, " Min Depth 3/4" A.B. <br /> or <br /> 4" Min. Depth Portland Cement Con rete. <br /> rtes: <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Dia eter of Pipe ch <br /> To be connected to any adjacent driveway pipe Y N <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total u ber of Storm Drain Inlets <br /> rtes: <br /> HEADWALL Yes No <br /> PAVED FRONTAGE: P ED Min. Depth A.C. over_" Min. Depth 3/4"A.B. <br /> measu;;ng Feet in length and Feet in width <br /> FEES <br /> -icroachment Permit base fee . . . . .540.00 <br /> e1 Inspection Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/or w/o pipe . . . . .55.00 <br /> a Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br /> ED Driveway w/ Box Culvert . . . . S80.00 <br />