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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all tie provision of this application,and that the description inchrded iathis moon ate correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is dse owner of the respective property,or is qualified to represent the owner;and <br /> 3. That helshe will assume full respousibaity for all liability forpersonai injury or damage to property which may arise out oftbe work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That m the event any claim of such liabMy is made against tBeCounty of San Amcliva or any departmeot aa3rcial or employee ihereoc he shall <br /> defend,indemnify and hold them and each dthem harmless for such claim;and <br /> S. That work shall be performed by the applicant and/or any representative ofthe applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Fiat Perusit;and <br /> b. That if permission is graded as requested,he agrees to do the work described in accordance with all toms,conditions and restriction ofthis and any <br /> attached included as general Provisions. <br /> r o <br /> Signature Da <br /> FIELD INSPECTOR COnKWXNTS <br /> EXISIM40 CONDITIONS«««««««««««««««««««« <br /> 1. DRIVEWAY: Noe ❑ Out Gravel ❑ Aggregate Baso ❑ Paved(poa) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away fmm Pavemest ❑ Towards Pavement ❑ Flat <br /> 3. PIPES:, Now Ezdssg-Type <br /> Other pipes in neighbodmd: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Attachment to neighbor's pipe: Yea ❑ No <br /> 4.HEADWALL: Yea ❑ No L� <br /> S. ASPHALT CONCRETE DBX: Yea ❑ Na Z <br /> 6..BARREMS along Right-of-Way <br /> 1. DITCH Yes ❑ No ® If fes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»>>>>> »»»»»»»»»»PERLUTREQUMEMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ® COMMERCIAL ❑ AGRfCULTU E ❑ INDUMVI.AL, ❑ <br /> PAVED with 2 "Min.Depth AC.over ___� Mm.Depth 3/4"A.B. <br /> Notes <br /> 2. PIPES: Largth of Pipe R-pkvd: Pt.and Diameler of Pipe Inch <br /> To be connected to ray adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No C <br /> Total Length: (with proposed) Total Number of Starm Dade bdets <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mia Depth A.C.over "Mrs.Depth 3/4"A.B. <br /> Measuring Fed in ieag4h sad Feet in width <br /> PEES <br /> Driveway Encroachment Permit brae foe............................$85.00 <br /> FieldInspection <br /> Driveway w/or w/o pipe......... .. __....... ..____ $9i_00 ❑Paved fsnmdaga ._. _ _..___5100 00+4.46/& <br /> ❑Drivewayw/boxCulvert....... _......__. _......._..$155.00 ❑Curb,(cutter,Sidewalk.......................$100.00+0.98✓ft <br /> Ccunte AComputer;c:lAccesslApplication for Parmits0riyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br />