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i. That heft hes read all the provisions of this ap o%and that the desmon inciaded'Mob application are correct to the bast of his/her _ <br /> knowlwdge;and <br /> 2. That he/she is The owner of the respective properly,or is qualified to repreewt the own w and <br /> 3. That he/she win assume fall respamar' lty for ail tiability for personal mjmy or damage to property whkhmay arise out of&a work desenbed above, <br /> or which may arise out of h aAw faihrne to do the workpco ided herein;and <br /> 4. That in the evert any claim of such liability is made against The-County of San kao=of any deparmaeA of&cial or employee these4 he shall <br /> defend,indemnify and holdthem and each of them harmless for suck clam and <br /> S. That wait shall be performed by the applicant and/or any represents&e of the applicant in the County Ri*-of-Way at the above indicated site <br /> with a valid San Joagain Coun y Eacrwd ment Pence and <br /> 6. That if permission is granted as requested,he agrees to do the we&d in accordance with all terns,oondrli(i s and restriction ofthis and <br /> attached shoat,included a rare <br /> Signmtareafttpplicae�T$le Date <br /> FIELD INSPECTOR CO1 OARNTS <br /> »»»»»»»»»»»»»»»»»»»ENISTWO CONDnIONS««««««««««««««<«««««< <br /> t <br /> L DRIVEWAY: Now ❑ Dirt ❑ Gravel AW"deBase ❑ Pave004) ❑ Paved(Good) ❑ <br /> 2. SLOPING AwayA.Paw cit T.,,&P...,* ❑ Flat ❑ <br /> 3. PIPES:. Now ❑ E -Type <br /> Othapipes ianeigbbachood Yes No [� Approaches 0 Crow Drain ❑ Size <br /> Attadrment to ndgwm% Yea ❑ No Y��r <br /> 4.HEADWALL: Yea ❑ No' <br /> S.AStIIFALT CONCRETE DE1 L: Yea ❑ Ne, lJ- <br /> 6..BARRIERS along Rigbt-o&Way <br /> 9. DITCH Yes A�:W0 ❑ IfYew. V Style Point ❑ Other ❑ WWW <br /> Depth <br /> »»»»»»»»»»»»»»»»»PF.RbDTREQUMEMENTS<z««««««««««««««««««<< <br /> 1..IDEM.WAY.. SFR COMMERCIAL ❑ ADRICULTWLt ❑ INDUSTRIAL ❑ <br /> PAVED with "Min.Depth A.C.ova __ "Mm.Depth 3/4"A.B. <br /> Nates <br /> .2. PIPE& Lang*of Pipe R-pkod: FL and Disaider of Pipe inch <br /> To be oaaaected to auy adjacent y pipe Yea ❑ No <br /> DRADEWE Da ET REQUIRED Yea O No <br /> Toto Length: (with proposed) Totd Number of Slorm:DnfK Wets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AG over "Mm.Depth 3/4"A.B. <br /> Measuring Feetim lergth and Feet in width <br /> FEES <br /> Driveway FaCI+0 Wvne rt Permit base fee 019 <br /> ................it <br /> Fi Inspection <br /> ba-ay w/or w/o pipe.......... .._ _ ❑Paved&mta$e _. __. _____ 5100.40+0.461& <br /> ❑Driveway w/box Culvert._. .. _...... ❑C txb,Cater,SidowalL..:... ___$100.00+0.987& <br /> Co aalComputer,c_-V=sslApplioatiion fix Pem>its N yeway,and Paved Frontage Page.2 of 2 R:avlaed W/2000. <br /> r <br />