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: 'PLICANT HEREBY CERTIFIES: <br /> ha! De / she has read all the provision! this application, and that the descrip;ior �ncluded above are correct <br /> !o the best of his / her knowledge; and <br /> That he / she is the owner of the respective property, or is qualified to represent the o.s•ner, and <br /> That he / she will assume full responsibility for all liability for personal injury or dmage to property which may <br /> 3-;se out of the worts described above, or which may arise out of his/ her failure to do ;he 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 /> conditio s and rests ions of this and any attached sheet, included as general or special provisions. <br /> Sri <br /> Signature of Applicant -Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »»»»»»»»»»»»>EXI S TI N G C O N D ITi O NS«««««««««««< <br /> DRIVEWAY: None Dirt Grav I 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 ne ghbor's pipe: Yes No <br /> HEADWALL: Yes No, <br /> ASPHALT CONCRETE DIKE: Yes No <br /> BARRIERS along Right-of-Way '— <br /> DITCH Yes '�W— If Yes: V Style____ 2 Point-___ Other Width_„- Depth <br /> »»»»»»»»»»»»>P E R M I T 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 /> ;es: <br /> PIPES: Length of pipe Required: See Form R-17, Note 4 Dia ieter 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 /> D;es: <br /> HEADWALL Yes Nox <br /> PAVED FRONTAGE: PAVED wij!�—' h4in. Depth A.C. over " 1.11in. Depth 3/4"A.B. <br /> measuring Feet in length and Feet in width <br /> FEES <br /> �roachment Permit base fee <br /> d Inspection + .251ft <br /> Driveway w/ or w/o pipe . . . . .S`-_0`0 Paved Frontage . . . . . . . . 550.000 <br /> Dr veway w/ Box Culvert . . . . Sc=.00 Curb, Gutter, Si;ewaik . . .550.00 + .50M <br />