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0 <br /> CITY OF STOCKTON 6 6 3 5 5 <br /> .�few', <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY �� S�Wv5 2,J 5 <br /> Appllcanrs Name ----- —� r..A;+ Trr Oate <br /> (OwnadContramar) <br /> Address 1000-A Ortega WaY Pha11i914 632-8521 <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Ciry <br /> Pla ntia State fn Zip g287n <br /> Location of Proposed work,eta 5606 PacifiO, r <br /> Stockton CA l3-dam_ <br /> By _Date <br /> Owner/Contractor Address <br /> Esnmeting Staninq OeteCompiedan Data 07�n/01 _Permit expiration data — <br /> I(or We) hereby apply for an enroachment permit to carry out the following work: install 2 around water <br /> mnitorincr wells in the sidewalk. <br /> Tnv above nametl appilcant hereby wues*pvnnisnon to- PERMIT FEE .........................................$ 0 <br /> See Above Additional Footage fee...........................S,. <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............S 128 00 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions; <br /> Figure Attached <br /> Snow sketch abcve er 06191 to drawing submined J <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 the <br /> City harmless against any and all losses, costs, or damagfss resulting from injury to persons, death of person or damage to property <br /> 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 <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) 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 signin Note requirement of notifications and inspections. <br /> _Phone: <br /> Sgnvtl: <br /> lABermlllee 2ndRk 3rdRrunca <th-lkdilY/Slraet <br /> EO'd T06e 2,EG 602 NiN33 iIWN3d smaoI oi-IEnd £T:TT T002-ET-83d <br />