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City of Lod ENCROACHMENT Public Works Department PERMIT Permit Address 521 North Cherokee_Lane---Monitoring WellsDate 07/21!2003 Applicant's Name, Address —� -- - _ w_ mm `- - Phone (209)369-9421 Stephen G Muir P O Box 152, Woodbridge, CA 95258-0152 _Cellular (209)601-66940 Starting Date Completion Date n/a License No --- Phone (209)369-9358fx Contractor - Address Cellular Pursuant to the provisions of the Lodi hlunicipal Code the undersigned applies for permission o excavate construct andior otherwise encroach on City Street Right of way or Easement by performing the following NOTIFY USA(800)227-2600 48 HOURS PRIOR TO ANY EXCAVATION Work Description The work consists of installation of(3) monitoring wells at back-of-walk south_ side of Murray Street per Workplan dated April 20, 2003 Permit conditions attached area part of this Encroachment Permit Expiration of Additional Insured Certificate shall cause work to cease Necessapermits and a roval from regulating agencies and parties shall be acquired prior to start of work NOTIFY CITY INSPECTOR JERRY DEWALT 209 333-6836 AT START OF WORK 0 `� TC 14, CIO (Sketch) rr�� Permit void if work not started within 6 months of permit date V Conditions Attached Plans Atta ed Licensed Contractor required for this work Certificate of insurance In the owner's name which names the City of Lodi its elected and appointed Boards Commissions Officers, Agents and Employees"as an Additional Named Insured is required for Comprehensive General Aggregate in the amount of$1 000 000 per occurrence and Automobile Liability Insurance in the amount of$1 000 000 combined single limit Tre undersigned does hereby agree to Indemnify and save the City of Lodi free and harmless from any liability in accordance with the provisions of Sec 12 G4 040 of the Lodi Municipal Cede Permuttee is spec tically aware of Sec 12 04 290(hereof relating to the relocation or removal of said encroachment 1 future construction requires such relocation If the work for which this encroachment permit has been issued has not been completed by nla the City of Lodi shall have the right to Compiete the work and to file a Cause of Acton to recoup the City's expenses in completing the work and for all other costs and fees in accordance with the provisions of Sec 12 04 12200 Of the Lodi Municipal Code Date g�� Q Signed �� •_ /"E �� Required Improvement Security This permit is granted subject to all provisions of Chapter 12 04 of the Lodi Municipal code and to all general provisions and applicable spectral provisions as show on the attached Certification of Insurance Permit Approved-eljY OF LODI Driver Alllant_Ins Comp Gen Policy No CP0108267 Exp 07/09/2004 By /_ f , y "��- Automotive Policy No CA0101637 Exp 07/09/2004v Date Public Above Ground Other Policy Exp — W� _ -- - ----------- Public Underground eferr to to -- Jerry DeWalt/333-6836 Date— nspecled _ Date LV Private to be maintained or relocated by dwrrer as required Other Permit No 2003-095 Completed Date C -- Reviewed Date Fee $4-00 — Paid Inspector Copy File Copy J Permittee Copy PWD 002(Rev 6r97)