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THE[,,PPLICANT HEREBY CERTIFIES: <br /> That he /she has read all the provisionshis application, and that the descriptions luded above are correct <br /> to the best of his/her knowledge; and is <br /> That he /she is the owner of the respective property, 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 /> 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 Pavemen Flat <br /> PIPES: Nonefx Existing -Type <br /> Other pipes in neighborhood: Yes Na Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No-',Z <br /> HEADWALL: Yes N(�� <br /> ASPHALT CONCRETE DIKE: Yes No� <br /> BARRIERS along Right-of-Way <br /> DITCH Yes NoL,/,_ If Yes: V Style_ 2 Point_ Other Width_ Depth <br /> »»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: SFR COMMERCIAL AGRICU TURE 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 /> otes <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Diameter of Pipe�nch <br /> To be connected to any adjacent driveway pipe Yes Nq <br /> DRAINAGE INLET REQUIRED Yes Noa(—, _.I <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> otes: <br /> HEADWALL Yes NqN <br /> PAVED FRONTAGE: PAVED " Min. Depth A.C. over " Min. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> -icroachment Permit base fee . . . . .540.00 <br /> eld Inspection <br /> J9Driveway w/or w/o pipe . . . . .$50.00 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/ Box Culvert . . . . $80.00 Curb,Gutter, Sidewalk . . .$50.00 + .50/ft <br />