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Sep 22 99 02:08p Hori7-on Env 916 939 2172 I p.3 <br /> ' I <br /> CfTY OF STOCKTON <br /> DEPARTMENT OF PUBLIC..WORKS <br /> APPLICAT[ N Q�LC2 ACH NJ N PUBLIC RIGHT-OF-WAY _ �Q <br /> I Zd" Lr"yi•rir, p gt33S? (05)58 63Tq 0�! " <br /> UWArt;Name.'1 t Any-r �d Date <br /> nedcontramq <br /> Address s, We�� l R r'r� �� Phone�� <br /> cfty ��r ^7�^^Tei te czf �p O <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Lacadon of Ptaptrsed work,etc. .r�dt,D' / —`*t� ` Gt.4f•y Pty t <br /> - — J a <br /> ed antractor Address layDate <br /> Estimating stet"Date t,ompl~ X,: E*ragort Data <br /> I(or We)hereby apply for an enroachment permit to carry out the following work <br /> (J+ti L? <br /> ,t r <br /> The above named vWftnt h"bY MgLMt6PWMiW!Qn ed.- -PERMrr ..........................................S <br /> Scalshh®7664"Post ff"Routing-Request Pad Additional Footage Fee...........................$ �r <br /> Sewer Tap Deposit............................... <br /> Please ROUTING - REQUEST •' Ize <br /> L WJ READ To oY, _L—AL1 _ TOTAL DEPO5rr.............S <br /> ❑ HANDLE ' <br /> f ��• Building Permit No. <br /> ❑ APPROVE' Improvement Plan No. <br /> and I� <br /> ❑ -FORWARD - Supplemental Conditions: i <br /> RETURN ,� <br /> ❑ KEEP OR DISCARDr <br /> ❑ REVIEW WITH ME <br /> Date From <br /> Show lkvt&above or rater to drawldg eu6mtted <br /> IMPORTANT: Applicant hereby agrees to comply with all provislons of this permit as well as all applicable City ordinances, resolution&, <br /> standards and spedifications currently in affect,and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not most above requirements. Failure to comply will be cause for revocation,of permit. Applicant agrees to indemnify and hold the <br /> City harmless against any and all losses, costs, of damages resuhing 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 City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE_ALERT (1.600.642-2444)TWO WORKING DAYS BEFORE BEGINNING l <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> IIS <br /> PERMITTEE SHALL CALL(209)937-00"-LWHOURS PRIOR TO-START OF WORKFOR A CONTROL.NUMBER AND TO SCHEDULE <br /> INSPECTION.. <br /> Read General .Provisions on reverse side of this e h ore signing tate regtJiren ent of 'notifications and inspections. I <br /> Phare: 9« 93f '2(7Z) <br /> tst.Permktns Ynd•Fne 3rd•F7ne�ca Mh•UdlhyJ$Iree[ <br /> ii <br /> 1 P <br />