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THE APPLICANT HEREBY CERTIFIES: <br /> I. That he/she has mad aft the provisions of this application,and that the destaiption inchi&d intl+is application are con ad to the bast of his/her <br /> knowlwdge,and <br /> 2. That helsho is the owner of the respective property,or is qualified to tqresent the owner;and <br /> 3. That he/she will assume full responsibility for alt tiatnlity A rpasanai imary ordamag;e to property which may arise out ofthe wort described above, <br /> or which may arise out of Wier failure to do the want provided berek and <br /> 4. That in the event any cLaim,of suchliability is made agamst t wCouily of San 7oagima or any depertment,official or empkoyee th reco he shall <br /> defend,indemnify and hold*=and each of them harmksa for su h cm.;and <br /> 5. That work shall be performed by the applies*and/or any rWamtdive of the applicant in the County Ri*-of--Way at the above indicated site <br /> with a valid San Joagain County Encroachment Pe m*and <br /> b. That if pemussim is granted as requested,he agrees to do the work described in acootdaaee with all teams,oonditims aid reattictien of ibis and any <br /> attached sheet,included as geaerai -70 <br /> or sp�eci��al Il��l /�hos <br /> �12s�.lylll� 4GiG/1_iPf�(lr/l?f� Z +�� <br /> SignakmofApp)iesnl�-Title Date <br /> FEELD INSPECTOR COARW11-TB <br /> »»»»»»»»»»»»»»»»»»»E MS'TMOCONDITIONS««r«««««««««««<<«««««< <br /> 1. DRIVEWAY: Nom Dirt ❑ t Gravel ❑ Aute Base ❑ Paved(poa') ❑ Paved(Good) ❑ <br /> 2. SLOPING: AwayErom Pavement ❑ Towards Pavammat -❑ Flat <br /> 3: PIPES• Now F.htshtiag-Type <br /> Other pipes in neiighborhood: Yea ❑ No Approaches 0 Cross Dims ❑ Size <br /> Attachment to naiobl ' . Yes ❑ No L - <br /> 4. HEADWALL: Yes ❑ No <br /> S.ASMALT CONCRETE Yea ❑ No <br /> 6..BARRIERS along Right£Way <br /> `f. DITCH Yea ❑ No If Yes:- V Style ❑ 2 Point ❑ Other ❑ Whdth Depth <br /> »»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««<< <br /> 1.DRKVEWAY: SFR COMMMCIAL, ❑ AORICULTIAtL ❑ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth AC.over "Ifm.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPE& L,eugth of Pipe RaWkod: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent drivevmy pipe Yea ❑ NO <br /> DRAINAGE INIET REQUIRED Yee ❑ No <br /> ToW Length: (with proposed) Total Number of Sty Dralk Islets <br /> Nates <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Ddm.Depth A.C,over "Ma Depth 3/4"A.B. <br /> Measming Feet in k"&and Feet in width <br /> FIEFS <br /> Driveway hicroadmun t Pem)k base fee......................... 5. <br /> Fi ld Inspection <br /> y w/or w/o pipe.......... ..- _- _ -595. ❑Pave d ftoata$e..._.--.-..:—_..--....5100.00+0.46/& <br /> ❑Driveway w/bos C uheR.-..-....-........--.. _..._....__. 155.00 ❑Curk Gutter,Sidewalk...................$100.00+0.98/ft <br /> CounterkCompi ter.c:lAccesalApplicationfor PamutsUkiyaway and Paved Frontaga Page.2 of 2 Revised 8/2000 <br /> � s <br />