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liii'f 2111111VLJ.1\1111:/1\l%Li ViLllij(jj,/�� <br /> 1. That he/sha has read all the provisions of this application,and that the dwAption nschrded inth&application ate cowed to the bast of his/her <br /> knowhvdge,and ' <br /> 2. That he/she is the owner of the respective property,or is qualified to $re ownm aud <br /> 3. That he/she will assume full re ility for all liability fan•Pen"mi ny>acy,10r <br /> damage to propeLiy which may arise out aftha work described above, <br /> or which may arise out of hisAw failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against ffieCopnty of San Doagiva or my dam,oMcW or employee dwreaC be shall <br /> defend,kdem>¢'y and hold them and each ofthem harmlessfar suds c1,,,;and <br /> S. That work shall be perfozmed by the applica-4 and/or any representative a(the applicant in the County Right-of-way at the above indicated site <br /> with a valid San Joagain County Encroachment permit;and <br /> 6. That if pemahssion is as requested,he agrees to do the work descnbad in awacdsace wills all temps,conditions and rest<idion ofthis and any <br /> attached ems, as or special Iii on, <br /> Appliami-TAicDate <br /> FIELD INSPECTOR COMIM1EIVTS <br /> EX1STM CONDMONS«««««««««««««««««««« ' <br /> L DRIVEWAY: Now riv Det ❑ Gravel ❑ - A at.B se F] Paved(iwa•) ❑ Paved(Good) ❑ <br /> 2. &LOPING: Ayffmml Pam ❑ Towuas Pavaeosam ❑ Fyt lul <br /> 3., PIPES-, Now gxist�-Type <br /> tnPm mmhgb1harlwod Yes ❑ No Approaches 0 Crow Drain ❑ Si. <br /> ARad>ment to Yea ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S.ASPHALT CONCRETE DMU: ❑ No <br /> 6�.BARRIERS along RW-f-Way <br /> 4t <br /> 1. DITCH Yes ❑ No IfYes: V Style ❑ 2 Point ❑ Other ❑ Depth <br /> PERMITREQUIRF.IMM«««««««««««««««««««« <br /> 1.DR[W.WAY: SFR ❑ comm RCIAL A C;1RiCMTURE ❑ INDUMMAL ❑ <br /> PAVED with "hfi[L Depth A.C.over "1�in Depth 3/4"A.B. <br /> Notre <br /> 2. PIPE& Lam of Pipe Requjmd:- Ft.and DiAMMA r of Pipe Inch <br /> To be connected to any adjacent drivevay pipe Yes N <br /> DRAINAGE INIET REQUIRED Yes ❑ No <br /> Tom ( ProP ) Tadd NmWkr of Steen Dakin Idea <br /> Nates <br /> 3. HEADWALL Yes=;nM No <br /> 4 PAVED FRONTAGE: PAVED with "Wm.Depth AC.over "AfhL Depth 3/4"A.B <br /> Mpg Feet in leis and Fed inwidth <br /> FEES <br /> Driveway Enaoadhment Pen nit base fie....................... <br /> §ejpI Inspection <br /> Driveway w/or w/o pipe....._.. .._. __.. <br /> ElDriveway w/box CulveR._._. _........ .. _. ❑PavedfnontaSe _.. _ ._ _..__ S100.00+0.46/ft <br /> _....._..Si55.00 ❑Curb,Gutter,Sidewalk....._........_.....$100.00+0.9M <br /> Countft�Computer,c:\AcceselApplication for PamrtslDri 9eway and Paved Frontage <br /> Page.2 oft R,evlsed=000 <br />