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THE APPLICANT HEREBY CERMIES: <br /> 1. That he/she hes read all the Provisions of this WhCatioD,and tbat the description kokx ed irktl&application are correct to the bast of his/her <br /> knowhrdge;and <br /> 2. That he/she is the owner of the respective Property,or is gwMed to represent the owne,amt <br /> 3. That he/she will assume full responsibility far all liability for personal injury or damage to property whichmay arise out ofthe work desmbed above, <br /> or which may arise out of hislhar hitare to do the work provided heroin;and <br /> 4. That m the event any claim of such liability is made against the Cvunty of San 3oacliim or my department official err emploYee fluxeoi;he shall <br /> defend,indemnify and holdthem and each of them harmless for such daim;and <br /> S. That work shall be performed by the applicant and/or any representative of the applicant in the Cob Rightt of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachaxat Permit;and <br /> 6. That if Pwnisd0n is gnuted as requested,he agrees to do the w0&desarW in accordance with an trans,conditions and resfricdOn of this and any <br /> attached sheet,included as general or special IR provisions. <br /> 'X 2/6- <br /> Si oft"li..A-Tithe Date <br /> FIELD INSPECTOR CO1 VWZNTS <br /> »»»»»»»»»»»»»»»»»>}»»E)MT1140 CON;pNS«««««««««««««««««««« <br /> L DWI ZWAY: None Dirt ❑ t3ravei ❑ Aggregate Base ❑ Pave") ❑ Pav*Good) El <br /> Z SLOPING: Away from Pavement ElTowm&Pavmmaht ED FW <br /> 3. PIPES: Now ExWng-Type <br /> Other pipes in neigihhorhood: Yes ❑ No Approaches ❑ Crow Dram ❑ Sao LTA <br /> Attadmheut to neighbor's Yes ❑ No <br /> 4.JEUDWAL L: Yes ❑ No, <br /> S. ASPHALT CONCRETED , Yes ❑ No <br /> 6..BARRIERS ak"Rigbt c&Way <br /> 1. DITCH Yea ❑ No IfYes: V We ❑ 2 Point ❑ dfher ❑ Wrdth Depth <br /> »»»»»»»»» »»»»»»»»PERMITREQUIgEMENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL. ❑ AjOcUMM ❑ INDUSTRIAL ❑ <br /> PAVED with "Mia.Depth A.C.over "Mm.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPE& of Pipe Reece Pt.and Diameter of Pipe inch <br /> To be connected to any adjacent driveway pipe Yea ❑ No <br /> DRAINAOE INLET REQUIRED Yes ❑ No Ai <br /> ToW I axeth (wish proposed) Torsi Neer of Sborm Drdn 1141e6 <br /> Notes <br /> 3. E[EADWALL Yes ® No <br /> E: PAVED with "Mm A.C.over "Mm.Depth 3/4"A.B. <br /> 4. PAVED FRONTAD Depth <br /> Measuring Feet in tent&and Feet in width <br /> FEES <br /> Driveway Fncroacbma t Permit base See............................585.00 <br /> ra Inspection <br /> DriveWayw/or w/o pipe........ . .._._.. ...._.___..._ _ 595.00 ElPavedfroatage..�..__._..:.--..__......S100.00+0.46/R <br /> ❑Curb,Gutter,Sidowalk.......................$100.00+0.98/8 <br /> Countcr\Canputec c:\AccessVffhoahon for Pamitsllhiyevray and Paved Frontage Paget of 2 Revised 8/2000 <br />