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-H;. :- �DLICANT HEREBY CERTIFIES' <br /> - •e / she �.=s read all the prcvisionsohis application, and that the descriptio luded above are correct <br /> the best of his / her knowledge; and <br /> -^at he / she is the owner of the respective properly, or is q'.:alified 10 represent t'.e caner, and <br /> -.at he / she w^II assume full responsibility for all liability for personal injury or dmage to property which may <br /> cut of the work described above, or which may arise out of his / her failure to do :'e v:ork previcted for <br /> and any <br /> ^,at in the event anye thereOf.of such liaDility is made againsl he shall defend, indemnify and the County of hold them and san each oQthenrharmilessafors such claim; <br /> -•���cia1 or employee t e , <br /> ;nd <br /> ;hat no work shall be performed by the applicant and / or any representatives of the apalicant in the County <br /> .:Right-of-Way at the above indicated site without a valid San Joaquin County Encroachment Permit; and <br /> nat, if permission is granted as requested, he agrees to d the work described in accordance with all terms, <br /> -ondilions and restrictions of this and any attached sheet, included as general or spec al provisions. <br /> Signature of Applicant - Title <br /> Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»» >> »»»»»»»EXISTING CONDITIONS«««««««««««< <br /> DRIVEWAY: Non e✓\. Dirt Gravel Aooregate Base Paved(Poor) Paved(Good) <br /> SLOPING: Away from Pavement Towards Pavement Flat <br /> PIPES: None Existing - Type_ Cross Drain Size <br /> Other pipes in neighborhood: Yes No Approaches <br /> Attachment to n ighbor's pipe: Yes No� <br /> HEADWALL: Yes Ne <br /> i <br /> ASPHALT CONCRETE DIKE: Yes No_, <br /> BARRIERS along Right-of-Way <br /> DITCH Yes No-)�- if Yes: V Style2 Point_ Other Width____ Depth <br /> »»»»»»»»»»»»>P E R M IT REQUIREMENTS««««««««««««< <br /> ;:•RiVEWAY: SFRCOMMERCIAL AGRICULTURE INDUSTRIAL <br /> PAVED with 2" Min. Depth A.C. over Min Depth 314" A.B. <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 NAlu <br /> Total Length: _ (with proposed) Total ber of Storm Drain Inlets <br /> es: <br /> :-:=ADWALL Yes No—, <br /> �;,VED FRONTAGE: PAVEDwit�tvsin. Depth A.C. over - t.;in. Depth 3/4" A.B. <br /> =eel in len^+h and Feet in width <br /> .y - <br /> rL--- S <br /> cac'�ment Per'iit base fee . . . . .5= .' 0 <br /> c <br /> :ne c^ Paved Frontage . . . . . . . . SSJ.V'J + .25:4.1 <br /> 03 Curo, G ter, SI-te,.diK 550.00 + 50"ft <br />