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"`' APPLICANT HEREBY CERTIFIES <br /> That he /she has read all the provisions this application, and that the description_ .,cluded 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 /> 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 /> cnditi s a d rest 'ction f this and any attached sheet, included as generator special provisions. <br /> Signature of Applican - Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXIS TI N G 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 No Approaches Cross Drain Size <br /> Attachment to neighbor's pipe: Yes No-C4— <br /> HEADWALL: Yes No—,,k <br /> ASPHALT CONCRETE DIKE: Yes Not <br /> BARRIERS along Right-of-Way <br /> DITCH Yes Noi2L If Yes: V Style_ 2 Point_ Other Width_ Depth ' <br /> »»»»»»»»»»»»>P ERMIT 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 Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes Novi <br /> DRAINAGE INLET REQUIRED Yes Now <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets <br /> rotes: <br /> . HEADWALL Yes Not <br /> PAVED FRONTAGE: PAVED wit4. 9 " Min. Depth A.C. over " Min. Depth 314"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> f <br /> -nCroachment Permit base fee . . . . .S40.00 <br /> xldAn Driveway <br /> on <br /> D <br /> Driveway w/ or w/o pipe . . . . .550.00 Pared Frontage . . . . . . . . S50.00 + .2-5"t <br /> Driveway w/ Box Culvert . . . . 50.00 j_f Curb, Gutter, Sidewalk . . .550.00 + .50:'ft <br />