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CITY OF. STOCKTON - i ss PUBLIC WORKS DEPARTMENT 7 - 879 ' APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY I Philip Environmental Appiicar!t's Nam, Coro. Date 3/06/2008 APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owne Contract Add ress2meor 10 W. Sand Bank Road Phone 6i s`-2Ai-1s4s Subject to the General Provisions and Special Conditions, and all work must conform to the project's approved Storm 1 City Col umbi a State I L Zip 62236 Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc. In front of.- of the City of Stockton Storm Water Pollution Prevention Maintenance Staff Guide, whichever is applicable. 1717 South Center Street Stockton . ✓///p�/ / �j -Owner/Contractor Address Same - - By Estimated Starting Date 4/21/2008 Completion Date 1 'week Permit Expiration Date W/' I (or We)ihereby apply for an Encroachment Permit to carry out the following work: Note: Start date is estimated but not 1 .scheduled at this time, rive to var uric. permit appr..valc - PSC will conduct the installation of one gl`•oundwater monitoring-well toan approximate dep}}y+ Gn Fo=f, below around surface and enl lert sn;l and groundwater camplac ATTENTION:ApplicanVContractor—youare responsible to - replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 339 00 gutter from score mark to score mark adjacent to the parcel. remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ 0 i The above named applicant hereby requests permission to Sewer Tap Deposit.................. $ o I See':attached figure (NW-2A) TOTAL DEPOSIT ...... $ 339 00 Building Permit No. NA Improvement Plan No. NA ;. Supplemental Conditions: k PERMIT NOT VALID WITHOUT A t P CONTROL NUMBER. CALL (209) 937.8386 TO REQUEST A CONTROL f NUMBER NO LESS THAN 24 HOURS, BUT NOT It• EXCESS OF 72 HOURS PRIOR TO START OF WORK.; CONTROL#` Show sketch above or refer to drawing submitted b'• ^"• i I IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, j 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 not meet the above requirements. Failure to comply will because for revocation of this permit.Applicant agrees to indemnify and hold the City 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 of, or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk i Manager prior to issuance of this permit. : - IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. i � `l�dr.c ✓�i ' Signed: !2 Phone: 618-406-0823 i� 1s1 -Permittee (white) 2"0-Inspection (pink) 3rd-File (yellow) 41h -Finance (white)