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THE APPLICANT HEREBY CERTIFIES: _ <br /> 1. That he/she has read all the provisions of this"gwation,and that the description inclnrded inthis application are correct to the best of his/her <br /> knowkWge,and <br /> 2. That he/she is the owmor of the respective property,of is ggalified to repiresa t the owner,and <br /> 3. That he/she will assume fall responsibility for all tialility for personal injury or damage to property which may arise out ofthe work described above, <br /> or which may arise out of his/her failure to do the work poovided herein;and <br /> 4. That in the event any claim of such liability is made against dwComty of San Yomi a or any deparlmacmf,official of employee 1hereo9 he shall <br /> defuad,indemnify and hold*=and each of them harmless fef such claim;and <br /> S. That work shall be performed by the applicmit and/or any representative of the applicant in the Comity Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encs Permit;and <br /> S. That if permission is granted as iegmsted,he agrees to do the work desrn'bed in accordance wi k all terms,oonditions and restriction oftbis and any <br /> attached as general or special III provisions. 6 /_ <br /> Aigiiatme afApplicart-Pirie Date <br /> FIELD INSPECTOR CObII4[ENTS <br /> »»»»»»»»»»»»»»»»»»» <br /> EXISIMqO COMMONS««««««««««««««t«««««< <br /> t <br /> L DRftWAY: Nape ❑ Out , oravok ❑ AggnegateBase ❑ PavedUNW) ❑ Paved(Good) ❑ <br /> 2. SLOPING. Away Frohn Pavement ❑ Towards Pavammeot ❑ Flat <br /> 3., P1PE8:. Now ❑ E dstitmg-Type <br /> Oltmrpipes inneighbodwod: Yes ❑ No Approaches ❑ Crass Drain ❑ Size <br /> Attachment to neighbor's pipe: Yes ❑ No <br /> 4.HEADWALL: Yea ❑ No Z <br /> S.ASPBALT CONCRETE DIKE: Yes ❑ No <br /> 6..BARRIERS akommg Right-of-Way <br /> 1. xrcir, Yes ❑ No IfYes: V We ❑ 2 Pb t ❑ Other ❑ W-W& Depth <br /> »>>>>> »»»»»»»»»»PERhUTREQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AC3Rh--UI.TURE ❑ INDUSIRIAL ❑ <br /> PAVED with `— "Min.Depth A.C.over '� "W.Dghth 3/4-A.B. <br /> Nates <br /> 2. PIPE& Length of Pipe RzWkgd: Ft.and Dime/ m of Pipe -- — inch <br /> To be connected to any adjacent drivwvay pipe Yes ❑ No {B, <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Totg1 Length: (with Proposed) Total Number of SbaM.Dmrida Islets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min Depth A.C.over "ben.Depth 3/4"A.B. <br /> Measuring Feet in iagth and Feat in width <br /> FEES <br /> Driveway Encroachment Permit base fee......................... . .00 <br /> Inspection <br /> ewayw/KLD- or W.pipe.._..... ..... . _ ._ _ _$95.00 ❑Paved _ Slt>D.00+0.461& <br /> fraatagr� __.__�.._ <br /> ❑Drivewayw/borCulvert.._..... ............................ .00 ❑Curb,Cih n.,Sid.,JL......................$100.00+0.98/R <br /> CaunterlComputer;c:V==\Application for PerraWkiyeway and Paved Frontage Page.2 oft Revised 8/2000 <br /> i <br />