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S CITY OF STOCKTON <br /> DEPART c-7 2 4 1 <br /> PUBLIC WORKS DEPARTMENT U I <br /> APPLICATION F?R EN ROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name S«, T zLg Date `I-SS-'-d Z APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> / -707-c.?-231 <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address Z7O PC/E-.�.S S7�'C C Phone 701-c3'A 1 S work must conform to the project's approved Storm Water Pollution <br /> Ciry snn Oil-i4 State IfQ Zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> / P7evention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc.P6,1Pk S r e isms T it i <br /> Ad ialc JtYJ Z Y .5 � <br /> s �5-/ Fi� <br /> �o.-I ''`., r o. "ac 1067 ) <br /> Owner/Contractor Address r{_,�L//,��� cA -T I r16 Date <br /> Estimating Starting Date O cTe Zoog. Compleffon Date v/'tAzoPermit Expiration Date- I Z' I "0�z- <br /> I 1((o,a�r We) hereby apply for an Encroachment <br /> /Permit to carry out the following work: <br /> pro d r1 // 1•t-d `SA__yd_/2 <br /> JALCCCpr � !/ (`/.i t3 C Sp-/ .�L�- 1-7 Q-, J? -!gJ in �4.r SIueL,Lk <br /> ,. ; -T4 owls; <br /> 1, ,3 cf rete—o f .S�r/�G, On�nLc /Vo�� Si -oj4ie /�v,tud I.v;ll <br /> -TISK hC f� � tl� klAc_k2�� O yh,C Soi� 60/'�r it'>_S Writ fe nSLT/- ��c 3hODP/t <br /> The above named//applicant hereby requests per mission to- p <br /> SCC wN</cAt� SiTG��4N��r�><r+< PERMIT FEE............................$ <br /> 621 <br /> Col.�i0 ply - Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> R .( F.'NTF Sewer Tap Deposit.................... $ <br /> SEP ti ZOOZ TOTAL DEPOSIT.........$ C/ <br /> 3w . on <br /> Er: _ Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditiio�nns: AA. <br /> ,{j <br /> 1/colt lavay '^/—�]'�,,b �- �0� <br /> zl <br /> Show aketM above or refer to drawing submige0 �./ 0xe-1 A ^ _Z � ak <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 indemnity 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 HOURS 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 /> SUBDIVISION 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 OFTHIS <br /> PPEEERRMIT BEFORE SIGNING. �7 / <br /> Signed Gly" - � 1 Phone: D 7-'7-U-23 6F <br /> ist-Permiffee(white) 2nd-Inspection(pink) 3rd-File(yellow) 41h-Finance(white) <br />