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0 0 640T( <br /> COMA CITY OF STOCKTON PAYMENT <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0 <br /> Aa# f <br /> D <br /> LP4� vC0 � �ecf,,� 60rronr SAN JOAQUiN ,iiJ!%11Y t PUBLIC HEALTH SERVICES <br /> ^ ,Ln rQ S`lC�1-.C..__�O_Q�_ . _ Data iQl1� ENVIRONMENTAL HEALTH DIVISION <br /> Applicant's Name lI�-! -/� <br /> (Owner/Con a or�Q X y/_j�' _ �. •! •SLD� Phone _'__.L- - <br /> Address_ r�o ULl-LIS• gN APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. <br /> Pl drmdoSt 6f_�ween C& h rMze/7on A•✓e• <br /> ( _L �I P.0.60)L� J�- —.lJ )-� Date -7 - <br /> Owner/Contractor Address �' (p�af Z 2Q <br /> Estimated Starling Date �� / /�' 9 Completion Dale <br /> Permit Expiration Date <br /> 1 (or We) hereby apply for an encroachment permit to carry out the following work <br /> 2hC s/ 74/11— Cj 0 <br /> a q / <br /> The above named applicant hereby requests permission to- PERMIT FEE........... . ... $ /IX °-- �00 <br /> IFIVI�- P(7U'Y/WG /' p-t(J/1/�h� �/ Additional Footage Fee.... - <br /> IS/4/leis 9 l� — <br /> cl 0/a.51,.,. Ik-k/j 'T- eCf- Sewer lap Deposit .. ...... _ — - _- <br /> pn /t.c.l\ • Q ftrcc�c� 7� <br /> tel' •'>< -O�^r�Cl.✓t 4� S�OI.I�/1 /'1 TOTALDEPOSIT ... $_ _. _l��-- 0a <br /> UrC z (/V w -a6 �• W�/ W/// b� Building Permit No. <br /> (O C4. 0 q I <br /> 'doir&db Sf(`e� 6e AJ`l Improvement Plan No. <br /> < /A Le��� _ Supplemental Conditions: <br /> CJ'tUrcG� .S 1�' <br /> C>� 0L Poe O <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applirani hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resOlufionS, <br /> ,'n• •ln•'1'. 4'"I 'b^'''"JP ''Iny n'1/in nffr;.t and to pa/to City its artilel Mst for removal and proper replacement of anv Item which <br /> . •P .. n'. i :;'�v'R '.. ;i"✓'J if t.k ':a'::*, r. . .r:Y... :y...... /-pp __ a_ ces t0 in,+e..'nlc., a-d hold <br /> CCP IY <br /> .. . . . .. . '." n','� ',♦'F: .. . _ .. _ .: _: - .5 :_ ? _ -_ a __ ° _- ;.._ .._� .. :�? <br /> '+tr 1.._p . r t ' ". .T rJf•^cor:G�.t,r.1 tt7 �•'c a s•p�r ��.t •r'.-..'C`w D.�V _=GINNING <br /> W- RS =OR -_VN'. '.-'LITE: <br /> PERMITTEE SHALL CALL(22D91?;;-Satt 21 HOURS PRIOR TO START OF R'ORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION, <br /> Read General Provisions on reverse side of this permit before signing ; Note requirement of notifications and inspections. <br /> t�C. —tw o n,,,,! ANS—?73''111�4 <br /> V1 c) '4FN✓. .y2Vlcc_�' <br />