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r �]CANT HEREBY CERTIFIES:_. <br /> she !,as read all the provision) this application, and that the descrip:tor r_`uc`ed above are correct <br /> est of his / her knowledge; and <br /> e / she is the owner of the respective properly, or is qualified to represent the e.�ner, and <br /> ie / she will assume full responsibility for all IiabiE,y for personal injury or drnage io property which may <br /> out of t~e work described above, or which may arise out of his/her failure to do :`.e work provided for <br /> an d <br /> at in the event, any claim of such liability is made against the County of San Joaquin or any department, <br /> or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; <br /> hat no work shall be perform ed by the applicant and / or any representatives of the a?plicant in the County <br /> ;fight-of-Way at the above indicated site without a valid San Joaquin Coun,y Encroachment Permit; and <br /> -hat, if pe7ission is granted as requested, he agrees to do the work described in accordance with all terms, <br /> -.ondi:iors and restrictio this and any attached sheet, included as general or special provisions. <br /> Si . I'ature 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 rom Pavement Towards Pavement Flat <br /> PIPES: None Size <br /> Existing - Type _ <br /> Other pipes in neighborhood: Yes No Approaches Cross Drain <br /> Attachment to neighbor's pipe: Yes, No <br /> HEADWALL: Yes No, <br /> .ASPHALT CONCRETE DIKE: Yes NoZ\ <br /> 3ARRIERS - along !ght-of-Way <br /> DITCH Yes No If Yes: V Style 2 Poin� Other Width_]` Depth, <br /> »»»»»»»»»»»»>P E R M I T REQUIREMENTS««««««««««««< <br /> DR!VEWAY: SFR COMMERCIAL AGRICULTURE 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 /> .es: <br /> PIPES: -- Length of pipe Required: See Form R-17, Note 4 iameter of Pipe J_�Inch <br /> To be connected to any adjacent driveway pipe Yes No) <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> •es: <br /> Yes No <br /> �" IV,�;,VEDFRONTAGE: PAVcD witDepth A.C. over " M.'M. Dep:h 314"A.B. <br /> ^eas-"^ Feet in len;th and Feet in width <br /> r_--S <br /> oacn7-nt Permit base fee . . . . .S-:�.�� <br /> '^ca-.eway w/ or.v/0 . . . . .cc: _.� a P2�ed F.,on, .. . . . . . . S50.03 + .25" <br /> -?way w/ i:cx C ori . . . . S=_ LJ (� Curo, Gu,:er, ``;te.:a;k <br />