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JUL-15-2002 MON 03,39 PM GF-mr.ER RYAN FAX NO. 70 ^''93218 P. 02/02 tel~ CITY OF STOCKTON 670-177 PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Appplicant's Name 61- �� `� • pate rR�© 2 APPROVED:BY THE PUBLIC WORKS DIRECTOR (pwnedContractor) Subject to the General Provisions and Special Conditions,and all Address n� �y '-`L�'QD' P11oneCy q' �-T work must conform to the projecrs approved Storm Water Pollution City P w�� State-c---4- 7,p -/ y L�y _ prevention Plan to the City of Stockton Storm Water p pollution .�, � Prevention Mai terra e S Guide,whichever is appy Location of Proposed Work,etc.„�+ r -�'4"�( 't'VV'( --...— Owner/Contractor Address W_ Date Estimating Starting Date aa+�a. Completion pate +Z• rmlt Expiration Date — � 1 (o1,We) hereby a ply for an Encroachment Permit to carry Nt the following work: oYt-a:�r�►-+�1- , c Vr�. G�'l^S O 4�Urt„ t�r. _ v,/'t� S. „ The above named appkant hareby requests permission to- PERMIT FEE............................$ .✓- Additional Footage Fee............$ Trench Fee............................... $ Sewer Tap Deposit....................$ TOTAL DEPOSIT.........$ 06 Building Permit No. Improvement Plan No. Su lemental Conditions: u k oAa d ctf ' Z). a1 " �w1�iN I+IC3t tib[ Show skatch above or rater to drawing submitted , IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,resolutions, 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 not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City 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 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 of this permit PERMITTEE SHALL CAU..(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS 1411T S FORE SIGNIN Z Signed://�9 1st-Permltaee(white) `"2nd-Inspection pfnk) 3rd-File(yellow) 4111-Finance(white)