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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions ofthis applivtiM and that the descxip4i m kcbrded ietbis applications are correct to the beat of hislhar <br /> knowhvdge;and <br /> 2. That belshe is the owner of the respective property,or is gaafmfied to represent theownea;and <br /> 3. That hehhe will assume full responsibility for alt liability far'personal*cry ordamaW to property which may wise out ofthe work described above, <br /> or which may arise out ofhis/her failure to do the wodrproMed herei;and <br /> 4. Tbat m the eventny aclaim of mmch}d)My is made against thsComty of San kagiun or a�dam,officyai or employee thenad be shall <br /> defend,indemnify and holdibem and each of them harmless for such oI i,;and <br /> S. That work shall be performed by the appfica*and/or any representative of the applicant in tba County Right-of-Way at the above indicated site <br /> with a valid San Joagnia County Encroacbma t Pems t;and <br /> 6. Tbat if permission is granted as requested,he agrees to do the wo&desm9W in acoecdance widr alt teams,conditions and restriction of this and any <br /> attached sheet,'mdudc#as genial or III provisions. <br /> di <br /> Signetare of Title Date <br /> FEUM INSPECTOR COMMUM <br /> I- DRIVEWAY: Now ❑ Did Gravel AggregaftBase ❑ Paved(po ) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Amy fm m Pavement To%m ds Pavaamant ❑ FJat ❑ <br /> 3. PIPES• Now F.auating-Type <br /> otherpipes in neigbbodmood: Yes ❑ No Approaches 0 Cram train ❑ Sim <br /> Atta&nect to nagwmes pipe: Yes ❑ No [2� <br /> 4.JIEADWAM- Yes ❑ No <br /> ASPHALT CONCRETE DUM-. Yes ❑ No C <br /> �.RUUU .R•g awn;l;&-af-Way <br /> 7. DUCK Yes ❑ No Ifyes:. V Style ❑ 2 Point ❑ Pd-11 ❑ Widtb Depth <br /> »»»»»»»»»»»»»»»> PERM17 RE 7JUMICENTS««««««««««««««««z«««< <br /> 1.DRIVEWAY: SFR COMMRCIAL ❑ AQRt4,-MTM ❑ IlVDusnUAL ❑ <br /> PAVED wilts2 "Tv1aa.DV&A.C.over 4 "Ids Depth 3/4"A B <br /> Nates <br /> 2. PIPER: Length of Pips Required:' Fk and Diaav eDer of Pipe inch <br /> To be connected to my a4aced driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yes ❑ No ] <br /> ToW Imob (WM proposed) ToW Nu mbw of Storm Drift bdefw <br /> Notes <br /> 3. HEADWALL Yea ® No . <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "ETm.Depth 3/4"A.B. <br /> bteaauing Fed in leng h and Feat in width <br /> FEES <br /> Driveway Encroachment Penin base fee..........................$95.00 <br /> 1 field Inspection <br /> ❑Driveway w/or w/o pipe............... __.._ 595.00 ❑Paved finatage............._....___....$100.00+0.46/8 <br /> ❑Irivoway w/box Culvert. ._..._ ........ _..__..5155.00. ❑Curb,(latter,Sidewalk....:..........._.....5100.00+0.98/ft <br /> Cmntmr C= iter,cAAccesaMpplication for PamidslDriveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />