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- _ . ciafxursivarclury PUBLIC WORKS DEPARTMENT =� APPLICATION F� ENCROACHMENT O.N PUBLIC RIGHT %WAY Applicant's Name 4.I � co Date /_-Z b"" 3 APPROVED: BY THE PUBLIC WORKS DIRECTOR �� (Owner/Contractor) _ Subject to the General Provisions and Special Conditions, and all 111 Address y C a7 �o "LTc L? r- Phone - work must conform to the project's approved Storm Water Pollution N 1 ©6a 3 Prevention Plan or the City of Stockton Storm Water Pollution 3 city a f��! "^- G- State e4- zip Prevention Maintenance Staff Guide, whichever inapplicable. H =� L J Location of Proposed Work, etc. 4 M n,. � '3 � t Ao s Te GG'T e , Owner/ Contractor Address B P ' ' Date "T" 6j / T Estimating Starting Date l71 /'c t� a,BA 3 Completion Date .� e milt Expiration Date 9 I (or We) hereby apply for an Encroachment Permit to carry out the following work: o t G /n ' t TO " a < u/ k1 �a, i3 / oc � / oR in ate Feel0 fn aar to rim WGlI / J' m •i 1 E.,ra ✓ bee .1 a ,rc .Q enrc � � wf n !J :. �L�xr +L < F_ c ^ o � o4 +2 � �_ / OR rm7 fo / t GJ tl f7Y a a. s � � 1. • � e "' :,serf ; U - Si, 'tf ' 17 �7 tj� .� Ic / t,ucll / tLt / YZFYa/ �✓l F t.� CG/IY2 �i SGL The above name) applicant hereby requests permission to - PERMIT FEE .,.,,'... ", 00 - S • L Ej TIcL �a .x`r ()r ::Jr "`S Additional Footage Fee .. .... .... .. $ Trench Fee ....... .. ............. .... ..I.. $ Sewer Tap Deposit....... .. . .. . . .. . ... S TOTAL DEPOSIT . . .... ... S Building Permit No. Improvement Plan No. Supplemental Conditions: - i serm y sionch above or refer to Inswing submitted J _ IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as ail applicable Cityordinances, resolutions, Standards and Specifications currently in effect, and to pay to the City its actual cast 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 er this permit. A certificate of insurance shall be submitted to the City Risk Manager prior to issuance of, or as a result of, work to be performed und of this permit. PERMITTI EE SHALL CALL (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 INSPECT IONS, 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 .. ` Y WOR. , ,• READ GENERAL PROVISIONS ON REVERSE SIDE \O\F`T ISS''PERMIT'BEFORE SIGNING. sign ed:^ ?. ' / \ +.� -�. .'7&. /� /� �4-.. E� \ tI'- � ft �. _ tea} 1st-Permittee (while) r 2nd�pect on (pink) 3rd F le •(yello w ) ` 4th-Finance (while)