FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA•DEPARTMENTOFTR, 'ORTATION Page 2 of 4 STANDARD ENCROACHMENT PERMIT APPLICATION r/0 MIT NO. TR-0100 (REV.0712007) I `_ Vr22.Will this proposed project require the disturbance of soil? [21YES ❑NO 'f /V J (�o If"YES",estimate the area wilhfn Slate Highway right-of-way in square feet AND acres: small 8'diameter holes (le)AND (acres) estimate the area outside of State Highway right-of-way In square feet AND acres: (W)AND (acres) 23.Will this proposed project require dewatering? ❑YES [ONO If"YES',estimate total gallons AND gallonsimonlh. (gailons)AND (gattonsfmonth) SOURCE': ❑STORMWATER ❑NON-STORM WATER ('See Callrans SWMP for definitions of non-storm water discharge: htlp,/Nmv.dol.ca.govlhgfenvistormwater/index him) 24.How will any storm water or ground water be disposed of from within or near the limits of this proposed project? []Storm Drain System ❑Combined Sewer i Storm System ❑Storm Water Retention Basin ❑Olher(explain); nia PLEASEREAD THEFOLLOWING CLAUSES PRIORTOSIGNING THIS ENCROACMIENI'PERNfITAPPLICATTOiN The applicant,understands and hereln agrees that an encroachment permit can be denied,and/ora bond required fornon- payment of prior orpresent encroachment permit fees. Encroachment Permit fees may still be due when an application Is withdrawn or denied,and that a denial maybe appealed,in accordance with the California Streets and Highways Code, Sectlon671.5.All work shallbe done in accordance with Caltrans rules andregulations subject to Inspection andapproval. The applicant, understands and herein agrees to the general provisions, special provisions and conditions of the encroachment permit,and to indemnify and hold harmless the State,Its officers,directors,agents,employees and each of them(Indemnitees)from and against any and all claims,demands,causes of action,damages,costs,expenses,actual a ttorneys'fees,judgments,losses and llabilitles ofeverykind andna(ure whatsoever(Claims)arising out oforin connection with the issuance and/oruse of this encroachment permit and the placement and s ubsequent operation and maintenance of said encroachment for:1)bodily Injury and/ordeath to persons Including but not limited to the Applicant,the State and Its officers,directors,agents and employees,the Indemnities,and the public;and 2)damage to properlyofanyone.Except as provided by law,the Indemnification provisions stated above shall apply regardless of the existence or degree of fault of Indemnities. The Applicant,however,shall not be obligated to Indemnify Indemnities for Claims arising from the sole negligence and willful misconduct of State,Its officers,directors,agents or employees. An encroachment permit is not a property right and does not transfer with the property to a new owner DISCHARGES OF STORM WATER AND NON STORM WATER:Work within State Highway right-of-way shag be conducted In compliance with all applicable requirements of the National Pollutant Discharge Elimination System(NPDES)permit Issued to the Department of Transportation(Department),togovern the discharge ofs form waterand non-storm waterfrom Its properties. Work shall also be in compliance with all otherapplicable Federal,State and Local laws and regulations,and with the Department's Encroachment Permits Manual and encroachment permit. Compliance with the Departments NPDES permit requires amongst other things,the preparation and submission ofa Storm WaterPollution Protection Plan (SWPPP),ora Water Pollution Control Program(WPCP),and the approval of same by the appropriate reviewing authority prior to the start of any work.Information on the requirements may also be reviewed on the Department's Construction Website at: h itp://www.d ot.ca.govlhq/construc/storm wafer 25.NAME of APPLICANT or ORGANIZATION (PrintorType) E-MAILADDRESS City of Tracy zabih.zaca@ci.tracy.ca.us ADDRESS of APPLICANT or ORGANIZATION WHERE PERMIT 1S TO BE MAILED (include City and Z1p Cafe) 325 Civic Center Plaza City of Tracy, CA 95376 PHONE NUMBER FAX NUMBER 209-831-6452 1408-452-9209-831-4430 26.NAME of AUTHORIZED AGENT 1 ENGINEER(Print or Type) ISLE TTEROFAUTHORIZATION ATTACHED E-MAI L ADDRESS Parikh Consultants, Inc. I [Z] YES o NO Ltran@parikhnet.com ADDRESS of AUTHORIZED AGENT I ENGINEER(Include City and Zip Code) 2360 Qume Drive Suite A San Jose, CA 95131 PHONE NUMBER FAXNUMBER 408-452-9000 1408-452-9004 27.SiGNATURE IZEDA fAPP [CANT AUTHORNT 28.PRINTOR TYPE NAME 29.TITLE 30.DAT£ t Lam Tran CruZ Project Engineer 1 2/24/14 L