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f <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61580 <br /> APPlicam'f NameJ!//� C�9C J7/'.DJf Datels�/1Lc� <br /> (owner/Connector) n <br /> Address SLS--L,fZ �/Phone 574i�A113 r�3 . <br /> Location of Proposed Work,etc. <br /> iJ o S AJ L/MJ i� �r APPROVED: DIRECTOR OF PUBLIC WORKS <br /> owrrr/controctor Address ��. r2<� By not, <br /> Estimated Starting Date SIJ Completion Date��. 3 S Permit Expiration Date eZ-- !— .( -2 <br /> l <br /> 1 (or Wel hereby apply for an encroachment permit carry out the following work: Zti Z�—s�-M� <br /> 1 The above named applicant hereby requests permission to - PERMIT FEE ..._.............._...___ $ vc� <br /> Additional Footage Fee, <br /> Sewer Top Deposit .................._..........__.. <br /> TOTAL DEPOSIT .._ ......... $ � <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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 in 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. *Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 9448350 Phoni,6209 )-57 <br /> i <br /> Ist---fermittee 2nd-File 3rd—Finance 4th- Utility/Street <br /> r __ <br />