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. :I I . ZPY <br /> CITY OF STOCKTON 756' 26 - <br /> EPARTMENT <br /> APPLICATION FOR ENCROACHMENT.ON PUBLIC RIGHT-OF-WAY,.: 1 <br /> PSC Industrial <br />,OpoApplicant's Name nn t9a _ci n� r P Dates 8' 2012 APPROVED: BY THE-P S DIRECTOR <br /> (owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 210 West Sand Bank Road Phone 618-281=1543 and all work must conform to the project's approved Storm <br /> City Columbia State IL Zip 62236 - Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Waiter Pollution Prevention <br /> Location of Proposed Work, etc. In front of: Mainte ce Staff Guide, whic ver is applicable: <br /> 1717 South Center Street, Stockton <br /> Owner/Contractor Address By Date <br /> Estimated Starting Date JuJq 2012 Completion Date 2-3 days Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: . Start date is estimated for.: <br /> mid-June, based on- receiving SJCEHD ermit,.and'doordinatin schedule with others. . PSC <br /> will conduct the destruction abandonment of existing monitorin wells as 2art of-site <br /> case clo <br /> ATTENTION-:Applicant/Contractor-you are responsible to,. . <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE................... $ <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. 'AddFfianaLF�,ia + $ <br /> The above named applicant hereby requests permission to: !.-✓ �` <br /> e 1 .. $ [JQ �"- <br /> See attached figure. 572 69 <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit-No. N/A <br /> Improvement Plan No. N/A <br /> Supplemental'Conditions: . <br /> I•';::t ai l k T VALID <br /> CONTROL, NUR' �. <br />'I TALI_ (209) 937-8368 TO REQUEST <br /> NUMBER NO LESS THAN 24 I IAURS, BUT,NOT INGE&,S OI'72 HOURS PRIOR TO START OF WQ% <br /> PONO <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinaribes,,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 <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnity and hold <br /> the City harmless against any and all.losses,costs,or damages resulting from injury to persons, death of person or damage to property <br /> occurring at the site of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. ; <br /> IF THE WORK DOES NOT COMMENCE 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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE . <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> _40, <br /> Signed: ��Phone: 618-406-0823 <br /> Zs,-Permit►Pp (whitpl 911d _Incnnrtinn (nin41 Qfd_Filo (volt.,,.,, nth <br />