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r _ <br /> jj CITY OF STOCKTON ' <br /> DEPARTMENT Of PUBLIC WORKS y. <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-O&WAY <br /> Fi!iVIR(,%iuOAL HLALTH <br /> FEWA1T i�iEQVICE.S <br /> li ��'c. `� 55758 <br /> Addres `G <br /> Location of Proposed work,ete N /, APPROVED- DIRECTOR OF PUBLIC WORKS <br /> 1, a %Z�o5 d5gnyo�y,4_BAS_ <br /> J�antroctor N r BY Dote <br /> Estimated Starting Date Completion Date Permit Expiration Date <br /> — <br /> I (or We) hereby apply for an encroachment permit to car out the following w rk: �� 1154'yY Ova- z�b <br /> w <br /> cr, l'4 -7 , N. <br /> 995VA>A _-577N c -r`R <br /> IL <br /> �i <br /> The above named applicant hereby requests permissi(to- PERMIT FEE............... ... _ <br /> Additiorwl Footage Fee....._.... .... .............. <br /> Sewer Tap Deposit ................................... <br /> TOTAL DEPOSIT $ <br /> Building Permit No. <br /> Improvement Plan No. ' <br /> Supplemental Conditions. <br /> fuer rfXegA i'i7 QLGdTG/s,vcG <br /> y3/P! <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, <br /> resolutions, standards and specifications currently."tn effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing. *Nola requirement of notiflc tions and Inspections. <br /> Permit Engineer/inspector �# <br /> 944.8492 <br /> is 944-8388 � Signed Pho e7 <br /> p Il <br /> I <br /> lst—permittee 2nd--file 3rd—Finance 4th—.utility/Str"t <br /> 4 <br />