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-HE APPLICANT HEREBY CERTIFIES: <br /> That he 1 she has read all the provisions of Oapplication, and that the descriptions inod 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 i the event any claim of such ee therreof, he shallability imade defends indemnify and hold them andainst the County of san each of Joaquin <br /> hamll.essafor�such claim; <br /> officiall or employ <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 /> Signature of Applicant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»» > »»»»»»EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Gravel Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement Towards Pavement, Flat <br /> PIPES: None,, Existing -Type roaches Cross Drain Size <br /> Other pipes in neighborhood: Yes NoApp <br /> Attachment to ghbor's pipe: Yes No <br /> LX <br /> HEADWALL: Yes NOK <br /> ASPHALT CONCRETE DIKE: Yes, No <br /> BARRIERS along Right-of-Way <br /> DITCH Yes No�, If Yes: V Style,_ 2 Point_ Other Width,_ Depth <br /> »»»»»»»»»»»»>P ERM IT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR COMMERCIAL AGRICU 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 /> Mes: <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 Y s Na <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> otes: <br /> . HEADWALL Yes N6 <br /> PAVED FRONTAGE: PAVE wi " 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 . . . . .540.00 <br /> eld Inspection <br /> (� Paved Frontage . . . . . . . . 550.00 + .<5!Driveway w/or w/o pipe . . . . .$50.00 t <br /> ��` Driveway w/ Box Culvert . . . . S50.00 Curb, Gutter, Sidewalk . . .$50.00 + .50/ft <br />