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' a City Of Lodi ENCROACHMENT Public Works Department PERMIT 7719- Permit Address 2- SOUTH CHEROKEE LANE Date: 02/13/2004 ._...._. ...._._..__.... Applicant's Name, Address Suxtc 306 Phone (916)679- ?o00 URS (Environmental)/Matthew Farr15 Crown Corporate Center,2870 Gateway Oaks Dr. -�!"CCQw.ek,toCellular �Iro Sd,Z _LSL/7i Phone �00—L11�,,- ) Starting Date Completion Date n/a License No L Contractor ��cw �� n\\ Address Cellular Pursuant to the provisions of the Lodi Municipal Code,the undersigned applies for permission to excavate,construct,and/or 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 as described in submitted Work Plan dated November 28, 2003. Permit conditions attached are a part of this Encroachment Permit. NOTIFY CITY INSPECTOR JERRY DEWALT, 333-6836, AT_START OF WORK. Refundable deposit for removal of utility related markings within public right-of- way submitted, 2/23/04. (Sketch) Permit void if work not started within 6 months of permit date. Conditions Attached d Plans Attached 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. The 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.12.04.040 of the Lodi Municipal Code.Permittee is specifically aware of Sec.12.04.290 thereof relating to the relocation or removal of said encroachment if future construction requires such relocation. If the work for which this encroachment permit has been issued has not been completed by nfa _ the City of Lodi shall have the right to complete the work,and to file a Cause of Action to recoup the City's expenses in completing the work and for all other costs and fees in accordance ith the provisio sof Sec .04.12 f the Lodi Municipal Code. / Signed Date ! © _._ Si g __.Z. ._ Required Improvement Security 2 This permit is granted subject to all provisions of Chapter 12.04 of the Lodi Municipal Code and to all general provisions and applicable special provisions as show on the attached certification of Insurance Permit Approved: CITY OF LODI - Comp.Gen. Policy No Exp By Automotive Policy No EXP _., Public Above Ground Date Other Policy: EXP ..........-:..__� ___.__. Public Underground Referred to .ler DeWalt 333-6836 Date — to be maintained or relocated by owner as required. _._...�. _. _......._......_...�..__....__........ d Private InspectedDate Permit No. 2004-020 Completed Date Other /; Reviewed Date Fee: Paid$107 00 _ _ Inspector Copy File Copy _Permittee Copy PWD-002(Rev.6197)