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CITY OF STOCKTON PUBLIC WORKS DEPARTMENT M95 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY plicani s Name RA M A GE ENV I R O N M E Wt bate rVU E S11 "02 APPROVED BY THE PUBLIC WORKS DIRECTOR S Owner/Contractor) Address � O. Ii 0 K 869 Subtest to the General Provisions and Special Conditions and all Phone 3 S 4-3 Z S 0 worts must conform to the protects approved Storm Water Polk ition City RA_NC H{1 M V R I E� State CA zip 95(a 63 Prevention Plan or the City of Stockton Storm Water Pollution Location of Proposed Work,etc 130 N. H v#I f!r R STREET Prevention Maintenance taff G ide,whichever is applicable EAST SiDt SIOE WALK Owner/Contractor Address «2x E, S C n 11 S AYE 1 STo C kTo N 8 Date (0�-z Estimating Starting Date T U LY 11.200Z Complebon Date TV LY 12 0 2 rmit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work INSTALL TWO OROvn WRT R 0NIT0FIN6- WELLS (4 GIlY Slpf-WALh. THE PVC P'MCNiTOKINfr WELLS WILL, 4E $E-LVRED WITH B-INCH DIAKETtµ _ rLVSH- vNTtD ?RAFT - A#kTtD MEET Soxr-s. THE 3IUEWALh SgvARES WILL DE SA W- rPT AND IkEMOVEDI AMU THE STREET B0 WILL 13E T IN c NCAL E COUD TO REPL CE THE REKONO SQVARES The above named applicant hereby requests permission to PERMIT FEE $ � Additional Footage Fee $ SEL SITE PLAN ATTACKEP Trench Fee $ Sewer rap Deposit $ TOTAL DEPOSIT $ Z ' Building Permit No Improvement Plan No Supplemental Conditions r-*e C,�PeS ayv-- �Po r&x Show sketch above or refer to drawing submitted L 1 IMPORTANT Applicant hereby agrees to comply with all provisions of this pemut as well as all applicable City ordinances resolutions, 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 not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnity and hold the City 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 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 of this permit PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL 0 COME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR BDIVISION IMPROVEMENTS PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937 8411 FOR ECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) READ GENERAL.PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING 4 Signed Phone ( 910} Z S 0 tst Permittee(white) 2nd Inspection(pink) 3rd Fite(yellow) 4th Finance(white)