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THE APPLICANT HEREBY CERTOUS: <br /> 1. That he robe has read all the provisions of this appiicatiotti and that the daaiptim included m this SFPlicatico are ooued to the bat of his/her ' <br /> kwwtm*c;and <br /> 2. That he/she is the owmw of the respective property,or is qualified to reprment the owner,and <br /> 3. That he/she will swum fall respooaib9ity for all fidgity for personal injury or daetage to property which may arise out of the wodc daaribed above, <br /> or which may arise out dhk&w 62me to do the work provided herein;and <br /> 4. That is the event any claim dutch lsaba7Ry is made again*the Comfy*San bagim or say depar%mr*,of3iciai or esoploy ee tl awt he shall <br /> Mend,indemnify and hold them and each ddhem harmieaa for uuh cLum and <br /> 3. That work shall be performed by the apphca*and/or any representative of the applicant in the Coudy R*bt-0f--Way at the above indicated site <br /> with a valid Sm Joaquin County Famoacbmest Prem and <br /> 6. Thst if patmisaion is granted as he ages to do the wade da nbW in aocordmoe wk h all teomr,conditions and restriction of this and any <br /> attached as general 4hia III <br /> N z —2 <br /> a <br /> S;gprre of Apph=m1-Tice Date <br /> F1F.IM INSPECTOR COMM►M <br /> >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>PJaMNO CONDMONS«««««««««««««««««««« <br /> L DRAWWAY: Now ❑ Dirt Orad ❑ Agg'eple Base ❑ Paved(poor) ❑ Paved(Oood) <br /> 2. SLOPING: Away Rmt Pavesoeot ❑ Towards Pavensed ❑ FLt ❑ <br /> 3. PIPES: Now �. Et3atieg-Type <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Ctna Drain ❑ Sire <br /> Attacbmmt to neigHm's pipe: Yes ❑ No <br /> L EMADWALL: Ya ❑ No, <br /> S.ASPHALT CONCRETE DEM Ya ❑ No <br /> 6. BARRUM &lcnaRW*-c&Way <br /> 7. DrrCH Yes ❑ No of— IfYa: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PFRMIT REQUIREWWM«««««««««««««««««««« <br /> L DRIVEWAY: SFR Q4, COMWERCIAL ❑ AORk;ULTURE ❑ INDLMMIAL ❑ <br /> PAVED with Z W.Depth A.C,mar "lltto.Daplh 3/4"A.B. <br /> Nda <br /> 2. PIPE& Leugm of Pipe Repaired: Pk sod DiaaWer of Pipe inch <br /> To be oomected to may ad}aou t driveway pipe Ya ❑ No <br /> DRAINAGE INLET REQUIRED Ya ❑ No AWL <br /> Tow Length (w1h proposed) Total Numbw of Stsmsm Dai Teich <br /> Nan <br /> 3. HEADWALL Yes Q No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "1Lfaa.Depot 3/4"A.B. <br /> Measuring Fed in le"gh and Fed in width <br /> FZBS <br /> Driveway Facroechnteot Pemoit base En... <br /> FieldInspection <br /> 91mveway w/or w/o pipe........ ❑Paved f mtaga...__-......_._._-._S1t10.00+o.46/ft <br /> ❑Drive--y,—/box( fvect.__ _..M..._......_.$155.00 ❑Curb,Gutter,Sidewalk....-.__........_5100.00+0.98//2 <br /> C-MMACampoter,c:kAooeaaWpliottion for Pamft Dnvmay and Paved Frontage Page 2 of 2 Revised 8/2000 <br />