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111G Hri ytt�.ru�a u.la...:.y - <br /> I. That he/she has read all the providom of this�and dist the descat ion included atthis apPlrcation ale correct to the best of.his/her <br /> kmwtwdge;and <br /> 2. That he/she is the owner of the teslactiva property,or is qualified to r the ownw and <br /> 3. That helske will assume fall responsibility fm'in ishiiily fo pmmml injury or damage to propertyw�ma'y arise OAofthe work described above, <br /> or whichmay arise out ofhis/her hilum to do the warlrprovided hmn4 and <br /> 4. That in the event any claim of such liability is made against lheCcxmty of Sam Doagim or ashy depm mm3f,official or=440YOO theme he shall <br /> defend,indemnify and hold*=and each of them harmless,for such claim;and <br /> 5. That work shall be performed by the applicant and/or any rive of the applicant in the County Right.-of-Way at the above indicated site <br /> with a valid San roagaia County Encroaohmeet Pemhif;and <br /> 6. That if as regiusted,ire agrees to do the wodc described in eco«dance wrtlh all ten118,000ditiorns and restriction ofthia and any <br /> Wedd m /7- <br /> Signalm ofApplicanr-Tial: nae` <br /> HUM LNSPECrOR cOP611d M <br /> L DRMkMWAY: Ncoe ❑ Gravel ❑ AW gate Hese ❑ Paved(i�) ❑ Ps�Cood) <br /> ❑ <br /> FZ SCOPING: Aw fibro Pavement ❑ Towards Psvmhent ❑ Flat <br /> 3: PIPES:. <br /> Now 0- Esisting-T9Po cC yE7 �t,�t.� Su 8,77✓1 S I t�� <br /> O&arpipesinneighbodeod: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> A"bnent to neighbor's pipe: Yes ❑ No Or <br /> 4.MADWAL,L: Yea ❑ No rfd <br /> S.ASPRALT CONCRLTE DIICE:; Yes ❑ No ILF <br /> 6..BARRn= ak"RigWoMay <br /> 1. DrPCS Yea )EL No ❑ IfYes: V Style 4'�Pbint ❑ Olbw ❑ Width Depth <br /> »»»>>>>> <br /> L DWWWAY. SFR COMMSRCL4L ❑ AORWMTW ❑ UMUSTRLAL ❑ <br /> PAVED with `L ."Mho.Deptls A.C.over _"frim.Depth 3/4"A.R <br /> Nates <br /> 2 PIPE& Length of Pipe Regairod: Ft sod Diameter of Pipe inch <br /> To be oaonected to any adjace t driveway Pipe Yea ❑ No L'7-- <br /> DRAINAGE INL.ETREQUIRED Yes 0 No <br /> Total Length: (with proposed) Total Number of Slnrnn Drat!)d <br /> Notes <br /> 3. HEADWALL Yes ❑Q No <br /> 4. ?AVID FRONTAgE: PAVED with "ddm.Depth A.C.over ")fat.Depth 3/4"A. <br /> Measuring Feet in 10010h and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............_......... <br /> ,F.,�'eyldI�patiaa <br /> C'�-BFivavvay w/or w/o pipe._....._.... ._.._ ❑Paved Tmaotage__.__._. _ _..___S100.00+0.46/ft <br /> ElDriveway w/box ..._........._....$155.00 ❑Cry,Gutter,Sidewalk.......................5100:00+0.981ft <br /> CourtalCa npi ter,mkAccesaWpplication for PermW1Driy_ Y and Paved Frontage Page.2 of 2 Revlsed 82000 <br /> I'� <br />