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TIE AFFLICANP HEREBY CER'EWWS:and that the description included inthis application are correct to the best of his/her <br /> 1. That WaU,has read all the provislans of this ap i0% <br /> kmowlwdge;and <br /> 2. Tbat heJshe is the owner of the MV'ctive property,a is quaiitied to represent the Owner;and <br /> far all 6abdity for personal injury or damage to Property which may arise out of the work described above, <br /> 3. That he/she will assuaLe full rety - <br /> or which may arise out of bistbar failure to do the work ptmMad herein;and of$ciaY rya thereof he shall <br /> 4. That in the avert any claim of such liability is made against*e County of Sia X)ag ern or any�, <br /> defend,indemnify and holdthem and each of them W=Aesa for such claw and <br /> the cant in the County Ri&-cf-Way at the above indicated site <br /> 5. That work shall be performed by the applicant and/or say representative � <br /> with a valid Sea Joaquin County Enc MA met Pe=ar and <br /> 6. That if peonission is gm ted as requested,he agrees to do the wodc described is accordance with all tewos,oonMons and restriction of this and any <br /> attached t included as general or III provisions. �,.' C)Lc� — <br /> " Dake <br /> Sigma of 'F <br /> FIELD INSPECTOR G'ObII S <br /> »»»»»»»»»»»»»»»»»}»»EXMTtNO CONDITIONS««<<<<<<«««««««««««« <br /> 1. DRIVEWAY: None ElDirt Gravel El Amesmtelkse ElP ) ❑ Paveci(t3ood) El <br /> SLOPING: Away from Pavement ❑ Towards Paveinoot Flat <br /> 2' " rru Plasf)c <br /> 3. PIPES- Now ❑ Existing-Type ('�� <br /> OdmrpipesinmYes No APPS CrosaDriia ❑ 3ize EFn <br /> Atfac med to neighbor's pipe: Yes ❑ No" <br /> 4.HEADWALL: Yes ❑ No <br /> S. ASPHALT CONCRETE DI KZ:' Yes ❑ No <br /> 6..BARRIERS slung Rigbkof•Way <br /> 1. DTPCH Yes No ❑ Ifym V Style Point ❑ O&W ❑ VPS Depth <br /> »»»»»»»»»»»»»»»»»»»PERMIT R1:rQLJII2EMENT <br /> 1. DRIVEWAY: SFR /� <br /> 00M 9ERCIAL ❑ AC}RjCULTE7RE ❑ 1NDUSTRML ❑ <br /> PAVED with "Mgs.Depth A.C.over Mia Depth 314"A B. <br /> Notes <br /> 2. P11ESe L-&th of Pipe Ragmhvd: Ft.sad Diameter of Pipe Inch <br /> To be connected to any adjace d driveway Pipe Yea ❑ No <br /> DRAINAGE)NUT REQUIRED Yes ❑ No <br /> TOW Length: (with p vpoeed) ToW N=Wkr e!Sborm Drala Inlets <br /> Nates <br /> F - <br /> 3. HEADWALL Yes ® No <br /> 4 PAVED FRONTAGE: PAVED with "Mur.Depth AC.over "lbtm.Depth 3/4*A.B. <br /> Measuring Fed in length and Feet in width <br /> FEES <br /> Driveway Fncroachmat Permit baso See............................585.00 <br /> Field Inspection <br /> Dryay <br /> ❑Paved 0. +0.46/ft <br /> iOWw/or w/o pipe.........._....._....._....._. _ 595.00 Curb, 3utr,siaork..:...... .........51ao.00+0.98/ft t <br /> Drivewayw/boxCilvert._...._._............. _..._......._5155.00 <br /> CountmkComputer,c:lAccem&Vkpplication for Perants0riyeway and Paved Frontage Page.2 of 2 <br /> Revised 8/2000 <br />