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CITY OF STOCKTON } <br /> 'I DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N2 62286 <br /> APplicont's No ✓� . r l� D. <br /> r <br /> !Owner <br /> Phone <br /> Ih <br /> Location of Proposed Work,etc. /rtJ/�r�Z APPROVED: DIRECTOR OF PUBLIC WORKS <br /> . �% 3� <br /> O�wser/Coettroetor Address W hh I ' ;' s l 7 /(.r /(r,�L,✓/ G <br /> Estimated StartingDate �i0`�r r 3 a� ` Permit Expiration Date �— <br /> � Completion Daro_.1�,-�3 <br /> I (or We hereby apply for a' a croachment permit to carry out the following work: <br /> IM <br /> iG <br /> The above named applicant hereby requests permission to- PERMIT FEE ......, <br /> Ali Additional Footage Fee. .. .... .. . .. ... . <br /> Sewer Top Deposit .................................... <br /> TOTAL DEPOSIT ........................ S <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions. <br /> RECEIVED <br /> it N QV 19 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> Shaw sketch above o,refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or i�damoge to property occurring at the site of or as a result of work to be perforated under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing. 'No a requirement of notifications and inspections. <br /> Permit Engineer/Inspect`r <br /> 944-8250 <br /> 9448366 Signed: Phone <br /> C(OPYlit.--Permieree 2nd--File 3.d--Finance Mh—Utii ty/Street <br /> I <br />