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CITY OF STOCKTON (� 1f r x 2 4 2 <br /> PUBLIC WORKS DEPARTMENT ��`'� �'-') <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC <br /> RIGHT-OF-WQy <br /> av h 2 ,005 <br /> Applicants Name /-�; �CL Sv tw► Date G' s APPROVED: BY THF rl�1��1� _ ( R�C��IRECTOR <br /> (Owner/Contractor) o- 5 I } ,"o" <br /> f / L Subject to the General ProviotjS�c�-�p�t�l/�o�ditions,and all <br /> Address L175 NA'skee-k Slide 456 Phone-5/d,8'5 6.3U3`r work must conform to the projects approved Storm Water Pollution <br /> `L/ / n� State A zip 946 1 Z Prevention Plan or the City of Stockton Storm Water Pollution <br /> City l a // Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc.\}��}tCic nC+✓� Si &,e-I— Ta-4,C S'� <br /> ami 6v'c3�.2,,�sa �,�� ,r0U. Oermit <br /> S G— <br /> Owner/Contractor Address By Date" C� _ <br /> Estimating Starting Date /�/� Completion Date Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: - /_/ 1,4/1 6x- <br /> ;l( c7i S c cno yl 5f 7-Lv�ll rKjrn i/ming �/��,�C ��c ��( ova %7� <br /> / Q o l lrc2 �- rl <br /> shwa - <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................ <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> _ ,rQ alletc`�-161( Map <br /> TOTAL DEPOSIT......... <br /> �e�o�h►e. 0-5–06 L,,,/ <br /> — <br /> BailrPermit No. <br /> o/toy v1- St X00 �t <br /> Sl0 Improvement Plan No. <br /> PERM Th�6nl��l i�lWRHOUT A <br /> Geta Qn w CONTROL NUMER. <br /> CALL (209) 937412W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted CONTROU <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,resolutions, <br /> Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed:-7-e`� 4 " h" Phone:Sly', E3&' 3C13 <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />