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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this apptication,and drat the dation included iathis application acs correct to the best ofhis/her <br /> knowh*q,sod <br /> 2. That he/she is the owner of the respective property,or is qualified to represent tiro owl and <br /> 3. That he(she will amore full mp msibr-lity for•all IiabirdY forpersonal injury or damage to properly which may arise out ofthe work described above, <br /> or which may arise out of hMw faiinre to do the work provided herean;and <br /> 4. That m the event any claim of strc h liability is made against therCo9mly of San Joagiva or any deperlmeni�offidd or <br /> employee thereof he shall <br /> defend,indemnify and boldthem and each ofthem hamiless for nbch clans;and <br /> S. That work shall be performed by the applicant and/or any representative of&*applicant in the County Ri&-of-Way at the above indicated site <br /> with a valid San Joaquin.County Encroachment Permit;and <br /> S. That of permission is granted as requested,he agrees to do the work described is acoocdance with all terns,oaudtions and restriction ofthis and any <br /> attached sheet,inchtded as general or special III provisions. <br /> Sigvatme-ofAppHc=t-Titk <br /> Date <br /> FIELD INSPECTOR COIe+MENTS <br /> > »»EXiS'1'MCONDMONS«««««««««««««««««««« <br /> L DRItfEWAY: None ❑ out ❑ (travel ❑ AggegateBase ❑ Paved*W) [❑ Pav*Good) (.j <br /> X SLOPING: Awry fromPavamed Towards Pavement ❑ Flat ❑ <br /> 3. PIPES- Now Esisti -Type <br /> Otherpipes hineighborhoock Yes ❑ No Approaches ❑ Cross Drain ❑ Sao <br /> Attachment to neighboes per: Yea ❑ No <br /> 4. HEADWALL: Yes ❑ No' <br /> S. ASPHALT CONCRETE DACE:' Yea ❑ No <br /> 6..RARREMS aloag Right-af-Way <br /> 7. DITCH Yea ❑ Ndl-, IfYes: V Style ❑ Mint ❑ Other ❑ Width Depth <br /> »»»PERLUT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ ACsRtCULTEIRB ❑ INDUSTRIAL ❑ <br /> PAVED with Z— "Min,Depth A.C.over —Min.Depth 3/4"A.B. <br /> Now <br /> 2. PIPE& I—*of Pipe Required: FL and Dim wkr of Pipe iaoh <br /> To be connected to my adjacent driveway pipe Yea Q No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Taal Length' (wiih proposed) Total Ntm bw or Stw=Drdu Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "h1m.Depth 3/4"A.B. <br /> Mpg Fed is kng&and Feet in width <br /> FEES <br /> Driveway Enmoac�ant Permit base flee........................ ..585. <br /> FL�Drrv�- <br /> away w/of w/o pipe......... .. .___._._.__.. 595. <br /> ❑Paved firott�,.._.�_.....:___..__....5100.00+0.46!& <br /> ❑Driveway w/boxCulvat._...................._..... .._..... _.5135.00 <br /> ❑Crib,t3rrttor,Sidewalk....:..................5100.00+0.95/R <br /> CounterlCamputef,c:UcceaslApplioa>ion for Penn"DrWmay and Paved Frontage Page.2 of 2 Revised=000 <br />