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THE f,:PPLICANT HEREBY CERTIFIES:'That he /she has read all the provisions Wis application, and that the descriptions <br /> isuded above are correct <br /> to the best of his/her knowledge; and <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 /> , <br /> official or employee thereof, he shall defend, indemnify and hold them and each of them harmless for such claim; <br /> and <br /> . rformed by the applicant and /or any representatives of the applicant in the County <br /> That <br /> at the above indicated site without a valid San Joaquin County Encroachment Permit; and <br /> Right-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 /> BGG%RC2 Date <br /> Signature of Applicant-Title <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXISTING CON DITIONS«««««««««««< <br /> DRIVEWAY: None Dirt Graveyard Aggregate <br /> Bat a Flat_ed(Poor) Paved(Good) <br /> SLOPING: Away from Pavementh <br /> PIPES: None T pe f Existing - <br /> Other pipes in neighborhood: Yes + No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes NT_ <br /> HEADWALL: Yes N64— , <br /> ASPHALT CONCRETE DIKE: Yes No, <br /> BARRIERS along Right-of-Way <br /> V Style __ 2 Point_ OtherWidth_ Depth <br /> DITCH Yesz N� If Yes: <br /> »»»»»»»»»»»»>PERMIT REQUIREMENTS««««««««««««< <br /> DRIVEWAY: 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 /> otes: <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Di meter of Pipe —Inch <br /> To be connected to any adjacent driveway pipe Yes No <br /> DRAINAGE INLET REQUIRED Yes No <br /> Total Length: (with proposed) Total Nu ber of Storm Drain Inlets <br /> otes: <br /> HEADWALL Yes-- NG <br /> . PAVED FRONTAGE• P D w,#1]a ""in. Depth A.C. over " Min. Depth 314"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> ncroachment Permit base fee . . . . .$40.00 <br /> geld Inspection <br /> Driveway wl or w/o pipe . . . .$50.00 0 Paved Frontage . . . . . . . . S50.00 + .25/ft <br /> Driveway w/Box Culvert . . . . $80.00 = Curb, Gutter, Sidewalk . . .550.00 + .50/ft <br />