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H' "PLICANT HEREBY CERTIFIES: <br /> that he/she has read all the provisions tris application, and that the descriptions c^'uded 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 permissiois grant requested, he agrees to do the work described in accordance with all terms, <br /> conditions nd r strictions i and any attached eet, included as general or special provisions. <br /> igna re Applicant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»>,»»»»»»»EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Grav I Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away fro Pavement Towards Pavement Flat <br /> PIPES: None Existing -Ty e <br /> Other pipes in neighborhood: Ye No Approaches Cross Drain Size�Z <br /> _ . Attachment to neighbors pipe: Yes 140� <br /> HEADWALL: Yes No <br /> ASPHALT CONCRETE DIKE: Yes No� <br /> BARRIERS along Right-of-W <br /> a <br /> DITCH Yes No If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> »»»»»> »»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SF� COMMERCIAL AGRIC TURE INDUSTRIAL <br /> PAVED with 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 Z <br /> meter of Pipe h <br /> To be connected to any adjacent driveway pipe Yes NG <br /> DRAINAGE INLET REQUIRED Yes No,z�Y <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> Dtes: <br /> HEADWALL Yes Ne <br /> PAVED FRONTAGE: PAVED wit ` 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 /> -aid spection <br /> G .Driveway w/or w/o pipe . . . . .S50.00 0 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S80.00 0 Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />