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ACritta,rs A AJLALU .+.+..•.•�•���y:a....+. <br /> 1. That hedshehas read all the provisions of this ap Oq and that We descriptio included is this application are c orrectt0 best of his/her <br /> knovdwdge,And <br /> 2. That he)she is the Owner of the resQadrve property,of>s qualified fiu rgxesent$f0 owl and <br /> 3. That he/she will assume fall r bt 4 for Iii f'tabffity far pmwml Mury'Ordainage to property which may arise out oftha work descaibed above, <br /> or wN&may arise out ofWs&or failureto do the workptrrvidedherein;and <br /> 4. That in the event any claim of Such liability is made 8SAiast AcCounty of San load or MY depmrhmnk.offidd or eaVloym&=4 her shall <br /> defend,indemnify and hold*m and each of them barmless for such cbnm;and <br /> S. That wak shall be performed by the aMhca*and/(r any repmentative of the applicant in the Comity Right.of-Way at the above indicated site <br /> with a valid San Joaquin.County Encroachment Permtit;and <br /> 6. That if pannissi agrew desomW in a000rdanoe w1h alt turas,oonditims and restriedm ofthis and any <br /> attached abed,and u7cw as gm,-&[or special Ill W isims. <br /> i <br /> 3 -T DaCa <br /> FIELD INSPECTOR COBS <br /> »»»»»»»»»»»»»»»»»»»WMTRIM CM)MONg«««««««««««««««««««« <br /> t . <br /> L DR#-MWAY- Nage ❑ put Qravel ❑ AggmSafel ee Q Pavod(I►ocu) ❑ Paved(Good) ❑ <br /> 2. &LOPING AwayfranPavamed Tow-&Paworaot ❑ FW ❑ <br /> 3. PIPES:. Nano E -Type <br /> Otherpipm inneigw" oo& Yes ❑ No Approaches Crom Drain ❑ Sim <br /> Att cbmaat#o nei +oc's pipe: Yes ❑ No <br /> 4,I ADWAU- Yea ❑ No" 9L , <br /> ASMALT CONCRETE DIVE: Yes ❑ Na ALI <br /> 6..RARR>ILEtS ak"Right-aMay <br /> i. Dom Yes ❑ No IfYeo:. V Style ❑ 2 Pond ❑ Olhw ❑ Wifr Depth <br /> »>>>>> <br /> 1.DERIWAY: SFR ✓ "COMMERCIAL ❑ AORtCfJE.TURt ❑ INDUSTRIAL ❑ <br /> PAVED with 2 .^Ifim Depth A.C.ower 4 "Mia DV&3/4"A.B. <br /> Nates <br /> 2 PUM of Pipe Required;• Ft.and Dimulder of Pipe — — lob <br /> To be 000mdted to any adjaad drivwmypipe Yes ❑.No .64� <br /> DRAINAGE RG"REQUIRED Yea ❑ No <br /> Tota]Leo*- (with proposed) Total 14u36er of Sbma Dtda hieb <br /> Nates <br /> 3. HEADWALL Yes Q No <br /> +i. PAVED FRONTAr*R: PAVED with "Mm.Depth A.C.over "Mm.Depih 3/4"A.& <br /> Measuring Fed hi ICRIgh and Feet in width <br /> FEES <br /> Driveway F=end mm t Pamir base fee......... . ._..... .585.00 <br /> eld Inspection - <br /> yw/orw/opip&..__._..:_ __ _ $95. ❑Pavedfimtaga-......__._..:___.---.-..$100.00+0.16)& <br /> Driveway w/box Calvert._ _ _ __ S1SS.00" ❑Curb,Gutter,Sidewalk..:.._.. .... . $100.00+0.98/& <br /> CcunterlComputer,c.-Vwo=VVplioatim fir PwmWMiyeway and Pawed Frontage Page.2.�2 Rnvfabd 812000 <br />