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I¢Iuu2 07/05/01 TRU 12:59 FAX 1 916 861 0430 SECOR-SACRAMENTO • CITY OF STOCKTON • ) PUBLIC WORKS DEPARTMENT Li`> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 51 1 AypiicanCs Namel&10-4 t/7�� Date �-s'� APPROVED:BY THE PUBLIC WORKS DIRECTOR (ownericantractor) 1,, d� Subject to Me General Provisions and Speoldl Cwtddons,andall Address1_/�rl—_ ,� /' ' �0�Phone -�ad work mustcordnrm to the project's approved ft"Water Water PdWdon City f+»C'MC f�!Inob- - Stats 4sif .2ip 7 23 Preven6an Plan or the City of Stockton Slum Water Pomudon Aw Prevention MaiMsrran Staff Gultle,whichever is applloslbia- Locatfon of Proposed Work,etc. .e4me. K frm. —= _ r Owned Contractor AddressyI _ B ' Data 1 Estimating Starting Date _-Completion Date — f P mitt Expi ation Data I (or We)hereby apply for an Encroachment Permit to carry out the following work The db vs s hrd wolcwt iereer mgwsrs permurcn to- PERMIT FEE............................S y Additional Footage Fee............S ! Trench FOG..............._......-.,,,.. 8 y! sewer rap Deposit.--_...............6 TOTAL OEPOSiT.........E Building Permit No. Improvement Plan No Supplemental Conditions: aho.r akeleh suers w rsb.n rnerhp nc eW IMPORTANT: Applicant hereby agrees to comply With all provisions of this permit,as wed as ad applicable City Ordinances,maolutions. Standards and Specifications aurent)y,in effect,and to pay m the City illi actual cost for removal and proper replacement of any Item which does not meet the above requirements.Failure to comply will be cause for revocation of permit Applicant agrees to Indemnify and hold dre City haonless against any and all losses,costs,W damages resulting from btjury to persona death of person or damage to property occurring at ma sibl of,or as a resvh of,work to be performed under tits panni.A condloate of insurance shall be submitted m the Oily Rlsk Manager prior to issuance of this permit. PERMITTEE SHALL CALL(208)937-8386 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF M HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT-IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OFA CONT140L NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(288)937-8411 FOR _4p EClp1C INSTRUCT)ONS PRIOR TO THE BEGINNING OF ANY WORK.) READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERJd7 BERRPE SIG/MING. 1,1 t�/'/ y�•5 Slone / Pinna: 1gl-Pannitae(wore) 2na-dapecden(pink) 3rd-RIE(yecow) alMPlnarne(Whirs)