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• • 67760 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Miller Springs Remediation <br /> A plicanfsName fianagerlent Inc Date 4/21/03 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions,and all <br /> Address 2480 Fortune Drive 1;114,te 3Q Phone work must conform to the project's approved Storm Water Pollution <br /> State ICY Zip 40R07 Prevention Plan or the City of Stockton Storrs Water Pollution <br /> City eXl 0;tOtl Prevention M inten ce S Guide,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> Date <br /> Owner/Contractor Address Sanie B <br /> Estimating Starting Date 5 43n/("I -Completion Date ' r r erml Expir 'on Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Install yroundivater <br /> moni tori no ;/ell in flu h-rao nt d 'a l l box in i t ri r,ht-of-wayc^ I r r <br /> _ _ - _ o 2.28u) <br /> r: <br /> r lue <br /> The above named applicant hereby wuests permission to- PERMIT FEE. 138 00 <br /> S._ attached SICetch. Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit....................$ <br /> TOTAL DEPOSIT.........$ I38 00 <br /> Building Permit No. <br /> Improvement Plan No. <br /> S pplemental Conditions: <br /> RECEIVED <br /> Show sketch above or refer to drawing submitted MAY - 9 2003 <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THI ERMIT BEFORE SIG NG. ! 4( c� <br /> sign Phone: 5- 9--z6 ` -27537 <br /> ist-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />