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'i'HEAPPLICANT]HEREBYCERTMUS: <br /> 1. That he/she has read all the provisions of this appficstiM and that the des,46M inchided iathis application am owed to the best of hia/hes <br /> Imowhvdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent&a owned and <br /> 3. That he/she will assume fall responsibility for all liability for peisoinl iayrrry or image to WWWY which may arise cwt ofthe work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against theCvrmty of Sao Joagitm;or any depwimenk ofcial or employee theaeag he shall <br /> defend,indemnity and holdthem and each af them harmless for such claimq and <br /> S. That work shall be performed by the applic W and/or any rq=sentafive of the Spiel in the County Ri&-of-Way at the above indicated site <br /> with a valid San Joaq m C ,,ty E p and <br /> b. That if permission is granted as requested,he agrees to do the weak described in a000rdawe with all <br /> temps,ooiiditioos and restriction of this and any <br /> attached sheet,' as gamaat or p���, <br /> ; Sigrtultuft(WAppHcaet- We <br /> ls" dw 6 <br /> Of <br /> Date <br /> FIELD INSPECTOR CO11MEM$ <br /> ...>—>>>>7>>>>>>>>>>>>>>>>>>>>EMTM CONDITIONS««««««««««««..... «« <br /> 1. DRIVEWAY: Norio ❑ Out � } Gravel <br /> ❑ Agde Base ❑ Paoed(I-W) ❑ Paved(Good) ❑ <br /> 2. SLOPING: AwayR,an Pavamont Towards Pas>minm ❑ Flat ❑ <br /> 3. PIPES:. Now ® Egg_Type <br /> Other pipes in n6ebodM& Yes ❑ NU Apprwxhes ❑ Cross Drain ❑ 3ize <br /> Att to ms's p4. Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S ASPHALT CiONCRET'E DIKE: Yea ❑ No <br /> 6-.BARRIERS along Righter Way <br /> 1. DITCH Yea ❑ No Ifyes: V Style ❑ 2 Point <br /> ❑ Other ❑ Width Dvffi <br /> »»»»"""""'""""'>>>>>>>>PST REQS«««««««««««««««««««« <br /> 1. DRIVEWAY: SFR COMMERCIAL ❑ AGRiCULTURE <br /> INDUSTRIAL ❑ <br /> PAVED with 2 Ifm.Depth A.C.over y "Afin,Depth 3/4"AB. <br /> Notes --/--- <br /> 2. PIPE6k L009*of Pipe Requkvd: Pt.and Diameter cf pipe bwh <br /> To be connected to any adjacent driveway piQe Yes ❑ No <br /> DRAWAGE INLET REQUIRED Yes ❑ No <br /> fR <br /> 'Notes Total (wilh Total Number orStgrin Draia mica <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm Depth AC over <br /> "Min.Depth 3/4"AB. <br /> Mfg Feet in length and Feet in width <br /> Driveway Encroacbmut Paomit base fee............................$85.00 FEES <br /> Field Inspection <br /> MDriveway w/or W/o pipe,....................Driveway w/box Culved.._......___... $95.00El <br /> Paved frontage _. . __..___.$100.00+0.46)R <br /> $135.00 <br /> _.. _... ...._._. ❑Curb,Critter S' <br /> rdewaDc...:....._...........$100.00+0.98/ft <br /> CounteACompute"c:WcceaslApplication for PelmitslDriveway and Paved Frontage <br /> Page.2 of 2 Revised 8&"1000 <br /> i <br /> I\. <br />