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53858 <br /> © CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR 'ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name j�i.c�e,; __ 1[-lktx- ?L_ Date <br /> (Owner/Contractor) <br /> Address P,O, BOL nV2- ICK _ � <br /> "_3�� D � <br /> ♦,j'� l� $ Cc APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. L��"'__—_—____ .__SF] <br /> Owner/Contractor Address See. /. 6je- _ B _ Date------- <br /> Estimated <br /> ate —__Estimated Starting Date —___ Completion Date l'(6 .._ Permit Expiration Date — 15� <br /> /t <br /> I (or We hereby apply for an encroachment permit to c rry out jPe following work : .-trl� Cc- Mei 1►� +�` _ to — �O <br /> ''-�•'t,µ.ce..�.,1 �t'e O U w s flee Q <br /> •hre4 ikcxdev- tei, so S Its, <br /> Y � rt 4��� �1 �► W�tt1� ,. See_- w <br /> e <br /> 1vo1^k- -6 a 4 . . 91, LI C -iLes w beaseK <br /> kv%� t� Fn-1 G W Lgw--t ;!�EE 0%- 4:+t_ <br /> els +� C-Cr`c CX-- <br /> s-rzrxTt:h�A �511P`>EZQA rirAerU:1yec, . <br /> The above named applicant hereby requests permission to- � 2-8 d0 <br /> PERMIT FEE........ ....... $__— <br /> Additional Footage Fee......... ... . <br /> Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... $__ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> J*4-Y -MAhifE l- LkA�11EE:&. <br /> NO -c-Q,r ex- 1."as-& <br /> 13Locic� <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 City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs, or damages resulting from injury to persons,death of person or damage to property <br /> occuring 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 <br /> City Risk Manager prior to beginning construction. 1 gw-(o0--I <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALE TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit Izef7act� <br /> sig ping — Note requirement of notifications <br /> '17 and inspections. <br /> Signed I PV-t.0.. - Phone !, <br /> 1st—Permittee 2nd--File 3rd—Finance 4th—Utility/Street <br />