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CITY OF STOCKTON ,AUG 0 4 28d�' F IL PUBLIC WORKS DEPARTMENT v - �,,P`TT,1501FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant s NameL-3 r DateI— ��s' } APPROVED BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor) Subject to the General Provisions and Special Conditions and all s C u til.- d. i of Qf Phone work must conform to the project's approved Storm Water Pollution City c. p 1 WL —State C G- ZipJ d,6;Z 3 Prevention Plan or the City of Stockton Storm Water Pollution �t Prevention Maintenance Staff Guide whichever is applicable Location of proposed Work etc M iyt--.- E-wwz ti lrs�� d Owner/Contractor Address B Date U IFstinlating Starting Date a rc a�b�4' Completion Date i, irmit Expiration Date / I (or We) nereby apply for an Encroachment Permit to carry out the following work / o c s (a _--�F�rTo 011 �4 41t,1"11 -!d/o Wk,-,_ k T, �oc.7lc.2 rn 7ta o -t �{ F,.A4 1 _ ,a-,:re L`' ��s f o `1` �.! Q p r�.Lzta 4S7_- a io _7/c•4 FTo Go-e, l,$ 1—<_-T (,2d d �.4- Tr,/1/ S 0 5 ac A�.. 4.a •t The above ramed appixant hereby requests permission to +S See A i{cc��A (�r..Jt� PERMIT FEE 5 , J Additional Footage Fee $ Trench Fee S Sewer Tap Deposit $ TOTAL DEPOSIT S ! r war Building PArmit No Improvement Plan No Supplemental Conditions i Show sketch aoove c rale o d awv+g subrx+itred I 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 res ilting 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 CALL(249)437 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 W1THiN 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 7 [Y WORK j ROENERAL PROVISIONS ON REVERSE SIDE F THrS FEFMIT-]BEFORE SIGNING / t s '� Signed �✓! �^. _ Phone t "L �c X 6- C 1st Permittee(white) 2nd}fispectio (pink)` 3rd FIe{yellow} 41h Finance(white)