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MENNEN <br /> 05/21/02 TUE 13:50 FAX 1 916 §110430 SECOR-SACRA4EYTO <br /> 10002 <br /> / CITY OF STOCKTON 66916 <br /> S PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Appl'canrs Name GbQ .1".FTY/��H�fd�K Date .S`'-0Z— APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> �' 4 ,�4 BA,, ps. �.�N Subject to the General Provisions and Special Conditions,and all <br /> Address Xt 'do *4v Phone MOyG 4yoo work must carrion to the projects approved Storm Water Foliation <br /> City��t.C.rf7 /rte State ZJp 9�0 Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintanancl StmrffGuice,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> owner/Contractor IAddress B Date -rs�-�. <br /> Estimating stating Date ��+�4 3 Completion Date r: rmit Ekpkittlon Dote —� y"7 <br /> I (or We) hereby apply for an Encroachment Permit to cant'out the following work: <br /> TJsrlt�L .r/Ow ''allivx r✓G <br /> I <br /> I <br /> i <br /> The ebm named*ppllranl herWy ieeown pennlaelon a. <br /> � 7 ' / PERMIT FEE............................$ v�! � " J' Addloonel Footage Fee............5 <br /> L- �J/ Trench Fee...............................5 <br /> Sewer Tap Deposit....................III-- <br /> TOTAL <br /> TOTAL DEP091T.........S �8 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> QMO 1oM, cloSvrca a,ra Per+u)�Ie9. <br /> I <br /> I <br /> Show*etch above ar miar le an V submaed <br /> IMPORTANT. Applicant hereby agrees to comply with all provisloue of this permit,as well as ell applicable City ordinances,resolutions, <br /> Standards and Specifications currently In o8ec4 and to pay to the City Its stow cost for removal and proper replacement of any Item which does <br /> not moot 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 she <br /> of,or as a result of,work to be performed under this permit.Acerifflcate of insurance shall be submitted to the City Risk Manager prior to isauance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)831-8366 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)037-9411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE BIDE OF THIS PER BEFORE IGNING. <br /> SlAnedl� H Phone: �/46�t5 01 'al—coo <br /> mr.Parmlese(while) 2nd-Inspection(pink) 3rd.Flfe(yellow) 4th-Finance(white) <br />