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' u 1 ..inn ^t�S �.. � - ,„;. ro -Mary,• -.� -� `� r.�7���w.-�-., "'"�5.k`4,, ''G�-3..'��"r � .y+'" T�' ;,�, -`'-.� `�_A'. <br /> a= '�vr,.h' »d,..? — lF � '�3 'K�" . fit ',: 7"?Y ,^ `"e, .i k 3.�,n�v• J2"�, "" <br /> 'n{` b <br /> �as,r '"� <br /> 7 <br /> �n <br />,r <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON Pu13LIC RIGHT-O&WAY <br /> ik- <br /> ( 18 4 <br /> Sarno/�nnrNxta) <br /> Adds ?._'`' <br /> ff /v APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Propowd Work.fl–z'lA' <br /> f <br /> Etfirnoted Slanting Date c� �—ComP4tion dal Petmll t:apirotim Dae� <br /> ..es-• ✓ <br /> G <br /> I (or We( hereby apply for on encroachment permit to carry alit the following work, A _ <br /> ��•� � rrnieelen to• PERMIT SEE................... S.J � <br /> Ttte above nomrd oppboont hereby request!t» _................. S— <br /> Additlonol 1`00400`0 Inn.... ........ ............ j <br /> Sewer Tap Deposit ` <br /> rv� TOTAL DEPOSIT....................... S <br /> Suliding Permit No. <br /> i <br /> Improvement Pian No. <br /> Supplemental Conditions: - <br /> i <br /> A 1 <br /> i <br /> Show sketch above or refer to droving eub nItted <br /> IMPORTANT,. Applicant hereby agrees to compty with all provisions of this permit as vel! os all applicable City ordinancesreel ce- <br /> resolutions,standards and specifications currently in effect, and to pay to City its actual cost for removal and proper eplae- <br /> ment of any Item which does not meet above requirements. failure tv comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and ail losses, costs, er damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. ' <br /> Head General Provis:ono on reverse side of this permit before signing. 'Nota requirementof notificationsand Inspections. <br /> Permit Engineerlinspectcr . <br /> grafi¢ // �itG <br /> Slpned: G•/'ter Phone [��g-?a$3 <br /> gaa•ss5s <br /> Iffermiflee 2nd--File 3rd—Finance 4th—utility/Street <br />