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;'HE DLICANT HEREBY CERTIFIES:_ <br /> -':a: ie I she has read all the provisions his application, and that the description " eluded above are correct y' , <br /> the best of his / her knowledge: and <br /> -hat he / she is the owner of the respective property, or is qualified to represent the oo; er, and <br /> hat he / she will assume full responsibility for all liability for personal injury or dmage to property which may <br /> ,r:se out of the work described above, or which may arise out of his/ her failure to do the work provided for <br /> e7ein; and <br /> -hat in the event any claim of such liability is made against the County of San Joaquin or any department, <br /> -4ficial or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; <br /> end <br /> hat 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 /> -o . n and restrictions o and any attached sheet, included as general or special provisions. <br /> Signature of Applicant - i Date <br /> FIELD INSPECTOR COMMENTS <br /> >.»»»»»> »»»»»»EXISTING C O ND ITI ONS«««««««««««< <br /> DRIVEWAY: None�Dirt Gravel Aggregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away fro Pavement Towards Pavement Flat / <br /> PIPES: None Existing T pe <br /> Other pipes in neighborhood: Ye No. Approaches Cross Drain Size <br /> Attachment to neighbors pipe: Yes No-ac <br /> HEADWALL: Yes <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 E R M IT REQ U I REM ENTS««««««« <br /> «««««< <br /> COMMERCIAL AGRICU TURE INDUSTRIAL <br /> RIVEWAY: with 2" Min. Depth A.C. over--7—" <br /> Depth 3/4" A.B.PA <br /> or <br /> 4" Min. Depth Portland Cement Concrete. <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipe <br /> inch <br /> To be connected to any adjacent driveway pipe Yes No- <br /> DRAINAGE INLET REQUIRED Yes Nt?—< <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> .es: <br /> iEADWALL Yes No <br /> ?AVED FRONTAGE: PAVc wit Nin. Depth A.C. over " Min. Depth 3/4" A.B. <br /> meas::r°n- Feet in length and Feet in width <br /> t ELS <br /> -oachme-t Permit base fee . . . . 0- 0 <br /> ^spe�`,-n <br /> r i Drr�-way w/or,y!0 pipe . . . . .S5^.-2,� Paved F rontsge. . . . . . . . S50.00 + .25/ft <br /> Dr,=way w/ B^x Culvert . . . . S! 00 0 Curs, Gu;:er, SiJe.va:K . . .550.00 + .50!ft <br />