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1'H;7 °'!�'LICANT HEREBY CERTIFIES: <br /> 2' ',e / she 1,2s read all the provisionshis application, and that the descriptions eluded above are correct ' <br /> to the best of his / her knowledge: and6 • <br /> Tt;at he / she is the owner of the respective property, or is qualified to represent the c.'ner, a.,� <br /> That he / she will assume full responsibility for all liability for personal injury or dmaye 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 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 <br /> Other pipes in neighborhood: Yes v' No Approaches Cross Drain Size <br /> _ Attachment to neighbor's pipe: Yes NoX, <br /> HEADWALL: Yes No <br /> ASPHALT CONCRETE DIKE: Yes No <br /> BARRIERS along bight-of-Way <br /> DITCH Yec<--� No If Yes: V Style_ 2 Point•; Other Width Depth <br /> »»»»»»»»»»»»>P E R M I T REQUIREME NTS««««««««««««< <br /> DRIVEWAY: SFR COMMERCIAL AGRICU -TUBE INDUSTRIAL <br /> PAVEith 2" Min. Depth A.C. over Z " Min Depth 3/4" 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 �`' Inch <br /> To be connected to any adjacent driveway pipe Yes No <br /> DRA,iNAGE INLET REQUIRED Yes No_,' <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> -es: <br /> HEADWALL Yes No <br /> PAVED FRONTAGE: PACED wilt ' ' Min. Depth A.C. over ' Min. Depth 3/4" A.B. <br /> measuring Feet in lencth and Feet in width <br /> FEES <br /> croachment Perm, it base fee . . . . .540.00 <br /> _1J Inspec ion <br /> Drveway w/ or w/o pipe . . . . .550.00 Paved Frontage . . . . . . . . S50.00 + 25/ft <br /> Dri.,eway wl Box Culvert . . . . S30.00 Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />