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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has read all the provision of this application,and than the descip ion kKkrded Mathis application we correct to the best of his/her <br /> knowhw%q and <br /> 2. That he/she is The owner of the respective property,or is qualified to represent the owner and ' <br /> 3. That he/she will assume full respOWlihilily for all nubility impersonal injury ordamage to property whish may arise out ofthe wodc described above, <br /> or which may arise out ofhk4w failure to do the work provided here®;and <br /> 4. That is the event any cla of such liability is made againd doComfy of San loagiva of any depert=4 owl or employee ihere 4 he shall <br /> defend,indemnify and hold*=and each of them harmless for such claim;and <br /> S. That work shall be perfamoed by the applica*andlor any rgxne8jstiW of&e applicant in the Cotmdy RiSbt-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachment Permit;and <br /> 6. That if pemnission is grauted as requested,he agrees to do tine wa&described in awordsnce with all terms,conditions and teshi and any <br /> attached sheat, <br /> . Da6a <br /> FIELD INSPECTOR COBBOO B <br /> »»»»»»»»»»»»»»»»»}»»WaSTtNQ CONDMON3 ««««< <br /> L DRIVEWAY: Nene ,Dot ❑ Oravel ❑ Awe Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> L SLOPING: Aw,Aa�yfimrPavamaut ❑ Towards Pavement E3Flat <br /> 3. PIPE&. Now Lam►—"" Exking-Type <br /> Other pipe in Yes ALWo ❑ Approaches ❑ Cross Drain ❑ Stu <br /> Aftaci meat to n*ohot'a pipe: Yes ❑ No <br /> 4 HEADWAILL- Yes ❑ No <br /> S.ASTBALT CONCRETE DDI : Yea ❑ No <br /> (~.BARRIERS along Right-of-Way <br /> 7. DITCH Yes ❑ No Ifyes: V Style ❑ 2 Poim ❑ Other ❑ WdthDepth <br /> >>>»»»>»»»»»»»»»»»»»»»PER=REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR j COMMERCIAL. ❑ AORtCULTEJItE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth A.C.over _"14m.Depth 3/4"AR <br /> Notes <br /> 2. PIPE& L-a*of Pipe Rapkvd:' Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINADE INLET REQUIRED. Yes ❑ No 01 <br /> Total 1,000k. (with Proposed) Tedd Number of Storm Dnkr Meta <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Wm Depth A.C.over "h1m,Depih 3/4"A.B. <br /> Meng �_ Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base flee............... <br /> eld Inspection ��"��,���///, <br /> yw/orw/o pipe......_.. _. _ _ _S95.00 ❑Pavedfiaetage......._.......—..___.S100.00+0.46/R <br /> ❑Drivenvay w/bog C lveR.__ . _. ......._.._._... ..__ SIS5.00 ❑Cuth,Gutter,SidMAL...:..... ..........5100.00+0.9m <br /> Con°terw4mputer,cAAooessVVptiaation for PamhMDriwmy and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br />