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HL' . ` PLICANT HEREBY CERTIFIES: <br /> at !ie / she has read all the previsions of� application, and that the descriptions inded above are correct <br /> and <br /> !^ the best of his/ her knowledge: <br /> `hat he / she is the owner of the respective properly, 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 /> anse 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: Yes3c"No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No <br /> HEADWALL: Yes NoC4 <br /> ASPHALT CONCRETE DIKE: Yes No <br /> BARRIERS along Right-of-Way <br /> DITCH Yes;_2C No If Yes: V Style_ 2 Point_ Other Width Depth <br /> »»»»»»»»»»»»>P ERM IT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR c� COMMERCIAL AGRICU T RE 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 /> )les: <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 /> DRAINAGE INLET REQUIRED Yes Nom,' <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> es: <br /> i <br /> HEADWALL Yes No <br /> PAVED FRONTAGE: PAVED with Min. Depth A.C. over " Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> :�-roachment Permit base fee . . . . .540.00 <br /> Inspection <br /> -71\Drivewa w/or w/o pipe . . . . .$50.00 <br /> Paved Frontage . . . . . . . . 550.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . S80.00 Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />