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Coe' 9;30 . C041.� o9P,z y oA <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT v b '-,v <br /> is APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 0 Applicant's Name Western Geo-"-1neers Date Q/39/01 APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address�8o G. Beamer Street Phone (�,�1n) Subject to the General Provisions and Special Conditions and all <br /> r30) tih8_5- Bork must conform to the projects approved Storm Water Pollution <br /> City State CA-- Zip 951776-6003 Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide whichever is applicable <br /> Location of Proposed Work,etc X336 &6400 Par+o f,r Avenue <br /> Stockton, CAtP�_ <br /> Owner/Contractor Address By Date —67 <br /> Estimating Starting Date 9/26/01 Completion Date rmit Expiration Date -' <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work Destroy =3.tor welle MW5 <br /> located in dirt area "road devides" 30 feet East of Pacific Ave. <br /> De3troy monitor well Mn78 located in dirt area 'r " c A,� <br /> and 100 feet North of Do las Road <br /> The above named applicant hereby requests permission to �..� <br /> PERMIT FEE $ <br /> Additional Footage Fee $ <br /> See Attached Figure Trench Fee $ <br /> • Sewer Tap Deposit $ <br /> TOTAL DEPOSIT $ <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT. Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances,resolutions, <br /> 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 <br /> not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the City <br /> 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 <br /> 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 <br /> of this permit <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOUF&OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> USDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PER/ITT BBEFO�RE SIGNING <br /> Signed Phone s.70 CC,? <br /> 1st-Permittee(white) 2 d Inspection(pink) 3rd File(yellow) 4111 Finance(white) <br />