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05/21/98 THU 13:26 FAX 209 948 0621 KLEINFELDER 10002 <br /> 64953 <br /> few', CITY OF STOCKTON <br /> OEPARTMENT OF PUBLIC WORKS <br /> - A; APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> pylic int's Name La 1 t� C - ., Date—SIAS_ <br /> Contractor) �5 �- ` yI <br /> Address_ _ _ �Tl� 5 Phoneq F3 t <br /> Location of Proposed Work,etc. �-�� APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner!Contractor Address I By Date <br /> Estimated Starling Data Completion pate Permit Expiration Date _ (o <br /> t� <br /> I (or We) reby appl for an encroac ent permit to carry ut the following work: ) Sal <br /> The above named applicant heraby requests permlaalon to PERMIT FEE.......... <br /> cJ� /: � A �r♦ G Additional Footage Fee... ......... <br /> � �rM vt ►��`�111�������,111�� VL Sewer Tap Deposit ................ _ <br /> TOTAL DEPOSIT......... $ C �I`�_ r <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> IC EEP 2 L *'1eb 7UO9 RC tom►:, <br /> t`>s Qal tx�- 4"u T� <br /> tx)oev- Inn\\ be- Ks�tckcA }C, <br /> 00 Pm Mcr:,fg-t <br /> Show sketch above or rater to drawing submitted - <br /> _ <br /> UP PtZtcfL ZL' " we Qn` 6 >; c1F b xziC <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 City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnity and hold <br /> the City harmless against any and all losses,costs,or damages resulting from injuryto <br /> 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 <br /> City Risk Manager prior to beginning construction. ti <br /> m <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-'a*a-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this perm before signing ote requirement of notifications and inspections. <br /> signed: --- - Phone-.V <br /> tst—Permittee 2nd—File 3rd—Finance 4th—UBFtylstreei <br />