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�� CITY OF STOCKTON DEPARTMENTIC WORKS 69527 <br /> SwcavU )ON FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's NameDate 6 / 27 / 05 APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address P nALTH Phone( 916 ) 677 - 081 S. Subject to the General Provisions and Special Conditions , <br /> tZ\/Irand all work must conform to the project's approved Storm <br /> City WesESStateCA Zip 95798 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. sidewalk ( Grassy area ) of the City of Stockton Storm Water Pollution Prevention <br /> P Maintenance Staff Guide, <br /> wh/iche r is appiicable . 5 <br /> 1400 block Grant St . North Side of Grant �����e��//�� L / / <br /> Owner/ContractorAddressP . O . Box 5785341 St • By �A Date D <br /> Estimated Starting DateMods torT� Qompletion Date 7 / 2 9 / 05 Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Placing one monitoring well <br /> ( MW- 14 ) See Attached Work Plan and Approval from RHD San Joaquin County <br /> ATTENTION : Applicant/Contractor — you are responsible to Z ? / `v <br /> replace all broken , damaged , and/or raised sidewalk, curb and PERMIT FEE . . . . . . .. . . . . . . . . . . . . . . . . . . $ J© <br /> gutter from score mark to score mark adjacent to the parcel ; . <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee . . . . . . . . . . $ <br /> The above named applicant hereby requests permission to : �— <br /> Sewer Tap Deposit . . . . . . . . . . . . . . . . . . $ <br /> TOTAL DEPOSIT . . . . . . $ <br /> eevocrblQ ImPJS_ d `�1 <br /> pr iPermit No. <br /> �� Improveve ment Plan No. <br /> Supplemental Conditions: <br /> PERMIT HOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937,%1&6 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> gEga�XCpE11S�S gO�.�yF, 7�2y HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted CON 1 9 OL9 <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 <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnify and hold <br /> the Cit harmless against an and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> Y 9 Y <br /> 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 <br /> Manager prior to issuance of this permit. <br /> IF THE WORK <br /> DOES NOT COMMENCE 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 IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937.8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) PRIOR TO ANY REOUIRED INS ECTIONS, AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT, PERMITTEE SHALL CALL (209) 937-8381 . <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFO NiG <br /> Signe Phone: <br /> 151 -Permittee (white) 21d - Inspection ( pink) 3rd -File (yellow) 41^ -Finance (white) <br />