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it <br /> CITY OF STOCKTON 67880 <br /> PUBLIC WORKS DEPARTMENT <br /> ii APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant me AdY61t Yd GW&F—NV) funiwtlrl ate -V4 703 APPROVED: BYTHE PUBLIC WORKS DIRECTOR <br /> (Owner od�ey a ) ` Subject to the General Provisions and Special Conditions, and all <br /> Address Y537 f'�Gi�,1�'._�6Lti� Phoney C9 I7�� work must conform to the projects approved Storm Water Pollution <br /> City 7 [G P ll' •1 V tJ State l.-FT zip 9 SZ 1 S Prevention Plante the City of Stockton Storm Water Pollution <br /> s. Prevention Maintenance Staff Guide, whichever is applicable. <br /> Location of Proposed Work, etc. rYb 'G d {z6'AR Vc.,t_ <br /> 7 � tb _L�L�S �aGitL»ti1 L'� B 6k <br /> DweZ��3 <br /> Owner Contrac AddressT_jg,# y <br /> Estimating Starting Date Completion Date Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Znsf tz l!-(_a� <br /> n.f�lrn ol rr ' !fit n S <br /> r <br /> A�/ HIJA)Lt r S.4-eR-4-) <br /> The above named applicant hereby requests permission to- Z3© Oo <br /> yy /� PERMIT FEE .......... ..... ...... $ <br /> /o i-C e-r, � Q 1-1-6G,`a , al/ Additional Footage Fee ........... $ c/ <br /> T p. �`L-C Trench Fee ............................... $ <br /> Doi Gal Sl1p Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ Z <br /> IT O <br /> Iwi1dmg�i�err�iiNa. .(I�-17, <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> l <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit.,as well as ail 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 REVERSES E OF THIS PERMIT BEFORE SIGNING. <br /> Slgned• r Phone: <br /> 1st-Pennittee(while) 2nd-Inspection(pink) 3rd-Rle(yellow) 4th-Finance(white) - <br />