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City of Lodi ENCROACHMENT Public Works Department PERMIT 771G- Permit Address 25a SOUTH CHEROKEE LANE Date 02/13/2004 Applicant's Name, w- Address aµ- 5�`tC dab– Phone (916)67_9- good URS (Environmental)/Matthew FarrlSCrown Corporate Center, 2870 Gateway Oaks Dr jc,�rolv�e„ToCeIIuIar (n5--'Y Z, Starting Date m Completion Date n/a mm — License No Phone Contractor 11<�g�UCVX� y�jn�1Address _ Cellular Pursuant to the provisions of the Lodi Municipal Code the undersigned applies for pemvssion to excavate construct and/or otherwise encroach on City Street Right of Way or Easement by performing the fallowing NOTIFY USA(800)227-2600 46 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 area part of this Encroachment Permit NOTIFY CITY INSPECTOR, JERR_YDEWALT, 333-6836, AT START OF WORK Refundable dei3osit for removal of utility related markingswithin 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 ' V 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 1 The undersigned does hereby agree to Indemnify and save the City of Lodt 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 construct+on requires such relocation If the work for which this encroachment permit has been issued has not been completed by nld ___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 casts and fees in accordance th the prowsi s of Se o4 12 f the Lodi Municipal Code Date Signed Required Improvement Security This permt is granted subject to all provisions of Chapter 12 04 of the Lodi Municipal Code / 7) / 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 _ try ' Automotive Policy No _mm EXP _ — Public Above Ground Date Other Policy - Exp ----- Public Underground Referred to Jerry DeWalt 333-6836 Date Private to be maintained or relocated by owner as required 1 InspectedDate W Other Permit No 2004-020 Completed Date Reviewed Date Fee $107 00 lr^/J' Paid - Inspector Copy File Copy Permittee Copy Pwo 002(Rev 6197)