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4c t . :2S • 88 14 : 11 0000 r:::4uS-SA1:, T•O P 1.5- 452- 0 58 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-ONWAY <br /> Awafitant"s Harr���� ��,Q, $YSt�R15 --.Dat* 1,�13�$S <br /> 57912 <br /> t�r+.rl t <br /> ,gyres Mission Blvd,, Fremont <br /> Latation of Propowd Work,ate N•W. Corner of Pacific, Ave. $ APPROVED: DIRECTOR OF PUBLIC WORKS <br /> March Lane <br /> Cr.~/Contractor _(satire as above) $ { JzL 0016 <br /> r-I imoted startl»p batt 10-T 6-8$ Cotripletlon Date l- - Perrnit FXP401ion par*_i r-c2-EB <br /> I (or Wel hereby apply for on encroachment permit to tarry out the following work; <br /> Excavate 2" diameter _b0reb0Jas p c-Qnduct soil vapor_.sury ._ Holt*--, �O to _ <br /> approxlma_te L_25'-30' below r -' <br /> immediately--backfilled as indi,,n,,ated below. Location o _ <br /> f halPct4_b-e_a_s shown on <br /> attached sketch. - <br /> The above non+id applicant hereby reClutfts pormiulon to _ PERMIT FEE ... .-_ - -_- .. S 50 00 <br /> Backfill of holes to be as follows! n!lditicnol Footau*r.. ... .".- .-...-. _.. . <br /> Sewer Top J]epovif •- ,.• .................. .. ..,._,., <br /> (1 ) Bentonite pellets or concrete grout <br /> to top of native soil . 1 50 00 <br /> 0TAL DEPOSIT .......... ..... ...•-- y <br /> (2) Concrete grout to within 4" of <br /> pavement surface. Building Permit No. _ <br /> Improvement plan No. <br /> (3) Asphalt Concrete to existing pavement <br /> surface. Supplemental Conditions: a <br /> Notify Underground Service Alert 48 hours <br /> prior to work. '-., <br /> Work to be performed on a Sunday morning, l <br /> A; <br /> Show Awch above or refer to drowrng subm,"ad <br /> • l <br /> IMPORTANT, Applicant hereby agrees to comply with all provisions of this permit cis well as all applicab#e City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removot and proper replace. <br /> merit of ony item which does not meet above eequiter"#nts. Failure to comply will be cause for- revocation of perrmit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to" <br /> persons, depth of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read Generei Provisions on reverse aide of this permit before slgning. "Note requirement of notifications and inspoctlons. <br /> Permit Engineer/Inspactor <br /> 9448492 �r+� <br /> d4$386 Signeds <br /> 4 <br /> z <br /> .3 3 3 — D- <br /> Isl�ermiti2e grid -•rile 3ra—.Finance 4th--Uhhty/sareee <br /> in <br /> Ilk <br /> 1' <br /> F', <br />