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�g s <br /> CITY OF STOCKTON 68244 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENTONPUBLIC RIGHT-OF-WAY <br /> , , �„Atyi.�c FP''MIA <br /> Applicant's Name, ��F.-,:tti+ich��.��TL� _- Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> ,_ r Subject to the General Provisions and Special Conditions,and all <br /> AddressJ�SQ C x pA � t7 // /�� Phone S rJ""� �' �1 work must conform to the projects approved Storm Water Pollution <br /> City � { State_t( Zip �1 50 L Prevention Plan or the City of Stockton Storm Water Pollution <br /> ti J Prevention Maintenance Staff Guide,whichever is applicable.. <br /> Location of Proposed Work,etc. Iv\ SI'lew.)4 Iiylrit tt�i- K ^A L i0 <br /> FgSA Ffer4 61- i r <br /> Owner/Contractor Address f I By Date <br /> Nl or (n L"t I 149r mp letion Date d s tv Sd S Permit zpiratio1 Date �L046 <br /> Estimating Starting Date p S <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: _E n t';,"o x;1,,A{ d0 1.1,1 to-.15i5 gin. <br /> jAaj-lq ; <br /> 0 tri! nine , hot-? Lie will ht dee s d11 t& R/ L`ri W—13 <br /> —...QdAdnidesW�i' l <br /> �ti{ rZll� 1�1lZtA Sdttn,4�t' t Grp ftiiSWiew f��IT.1d " <br /> I- fI DI.° ; -IM-11t W� 1 rl+I ( �.+ }ii- rid <br /> �CVVLk� if�li'1 Q Cid Y1 1�r1 1 e71 I�E'}� 4' fA`�L l�Z'Z r tub r�� <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE......................... $ ✓ f� mom.` <br /> Se- klr <br /> Additional Footage Fee............ $ <br /> �i Trench Fee ............................... $ <br /> Sewer Tap Deposit.................... <br /> TOTAL DEPOSIT.........$ <br /> f; Permit No. 06 � <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUR. <br /> CALL (249) 937-83B6 TO REQUEST A CONTROL <br /> NUMBER 1140 LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted C41ONTRO <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 the City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> . BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVE=MENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: � �� '�"1.-- ,�, Phone: _�;�jV'�Itv mul <br />