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THE !-,0FILICANT HEREBY CERTIFIES: <br /> That he/ she has read all the provisions o s application, and that the descriptions ir-�"Yded 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 d re rictions this and any attached sheet, included as general or special provisions. <br /> n cant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXISTING CONDITIONS«««««<"""""< <br /> Dirt Gravel Aggregate Base Paved(Poor) Paved(Good) <br /> DRIVEWAY: None <br /> SLOPING: Away from Pavement-( Towards Pavement Flat <br /> PIPES: None Existing -Typeross Drain Size--L2— <br /> Other pipes in neighborhood: Y� No Approaches C <br /> Attachment to neighbor's pipe: Yes No.( <br /> HEADWALL: Yes Ndg!�, Yes N04 <br /> ASPHALT CONCRETE DIKE: �. <br /> BARRIERS along Right-of-Way <br /> If Yes: V Styl 2 Point_ Other Width, Depth_ <br /> DITCH Yes, No <br /> »»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR K COMMERCIAL AGRICU TUBE INDUSTRIAL <br /> PAVED with 2" Min. Depth A.C. overMin Depth 3/4" A.B. <br /> or t' <br /> 4" Min. Depth Portland Cement Concrete. <br /> rtes: <br /> L_— <br /> PIPES: Length of pipe Required: See Form R•17, Note 4 Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes No4— <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total Num er of Storm Drain Inlets <br /> rtes: <br /> HEADWALL Yes Nolz.. <br /> iT� <br /> PAVED FRONTAGE: PAVED ✓w ' 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 . . . . .$40.00 <br /> ell Inspection Paved Frontage . . . . . . . . 550.00 + .25/ft <br /> Driveway w/or w/o pipe . . . . .$5...00 <br /> Driveway wl Box Culvert . . . . S80.00 <br /> 0 Curb, Gutter, Sidewalk . . .$50.00 + .50/ft <br /> 17 <br />