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NW <br /> Z# <br /> CITY OF STOCKTON 63489 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AIAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0[NI <br /> Applicant's Name ��_J_ ��(/�/' `��� Date_CL�- �995 <br /> (Owner/Contractor ENVIRONMENTAL MEALTH <br /> ) <br /> Address �� La610 11119 Phone 1L <br /> 12CLX,K � e-,4L� ��4/ ;79��j� u� APPROVED: P@WIQEA�r� <br /> OR <br /> Location oI Propos d Work, etc. <br /> Owner/Contractor Address _ _ B _ Date -7� <br /> Estimated Starting Date 4!;� 3���J Completion Date r Permit Expiration Date ✓' <br /> I (or We) hereby apply for an encroachment permit to cagy out the following work <br /> The above named applicant hereby requests permission to- PERMIT FEE _ .. . . .. . . .. .. $-4-2 ` <br /> Additional Footage Fee — <br /> Sewer Tap Deposit _- <br /> TOTAL DEPOSIT .. ... .... $__�t�'�' <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> 57.-�_ <br /> r <br /> 1P ex <br /> 0,z 0 10 11v <br /> Q_Z-< f ((/� <br /> Show sketch above or refer to drawing submitted <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 indemnify and hold <br /> the City harmless against any and all losses,costs, or damages resulting 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 <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> )S,qnod �v Phone f <br /> 1st—Permiltee 2n1 F,tn I'd Finnncn 4th—Utility/Street <br />