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a � �. #sem <br /> z6 8 311 <br /> CITY OF STOCKTON - <br /> PUBLIC WORKS DEPART MENTiV4 � 5� AQTP%4 rV <br /> ¢ S <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT=OF WAY } <br /> t QY1r,p "tAIRT Date "= APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> Applicants Name J _ ,K ,� <br /> (b wner/Contractor) Subject to tt�e Gee Pro�`ot s a spec 'Conditions,and all <br /> AddressM. <br /> 31 Oq�y � Phone9 1605-23V work mtast ooriform o theJprolecYs approve v"ed Sto_im Water Pollution <br /> Proverttion Plan or the t*bf Stockb m7 We1 r Pgllutiort q <br /> Grp M-P• :' o State"C4 _ Zip 9 5 cl37_ U <br /> City Prevention Maintenance Staff Guide whichever is applicable <br /> N- <br /> Location of Proposed Work,etc. <br /> By �. "pate <br /> Owner/Contractor Address <br /> a 3 Z_,( - Permit: lratlon.Date <br /> Estimating Starting Date ? Completion Date �; <br /> . G'. - t <br /> (or We) hereby apply for an Encroachment Permit to carry out the foflowing Wor . t <br /> axtr I Mt ,T <br /> NO <br /> i7:����tth <br /> - - <br /> 1�� .ia <br /> � <br /> The above named applicant hereby requests permission to• <br /> PERMIT FEE Ra-CIPMR—C%, <br /> wil <br /> , <br /> � S$Wef T$p <br /> Orr <br /> .r. .}. <?.\. '�.ir. +"+titrr r7 _ - •, 63' 'at,3 At 1.14 <br /> in <br /> rl' Impro�emerlt ,Iar>zNo �s 4, <br /> '�+ tl. •� -5 t,�Cw.r, .s a - '?"d' .,�F^+3" :��A�'�rxrE`:_':fir <br /> y�cY - Supplement rt Floaw <br /> ^Y �I R` e c w���Ir <br /> for /Cir <br /> Show sketch above or refer to drawing submitted "v/ • �+'! �� �, F C <br /> r':J'r - tib$° O <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well a;all ' SII <br /> s imrr <br /> Standards and Specifications currently in effect,and to pay to the City its actual cost for removal an spi or rep come art r,lt9m Which does <br /> not meet the above re uirements.Failure to rim I will because for revocation of permit Appli agyrees itlrnny artad�tha' i v! <br /> Qpy 3f <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of per9tanOtdnag$t ` ifperty.occ�lrlrtg at 1he_srte - <br /> of,or as a result of,wank to be performed under this permit.A certificate of insurance-shall be suYi fitted ty: g_ to issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOUFIS. T, QTINiE( '3 72;HOURS ; <br /> D O <br /> PRIOR TO THE START OF WORK,AND PRIOR 70 ANY REQUIRED INSPECTIONS,AS tDENTIFIIC Y�HE,IEIIERSE SiE C3F„j FfiS t <br /> PERMIT,IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OFA CONTROL NUMB ER'o7NE:COINO�I::NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR-CAPRAL MP)tOVaMt*NT;PROJECTS OR 1 <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECTEt�tG11VEER ATy�(-603'78411 f=QFt " <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) l _,? <br /> 6Jr <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: ' ``�"'' ,>•:., .rrfrone G f� _ <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-Rle(yellow) :;F�L4th-Flnance(white) <br />