Laserfiche WebLink
06/23/20p3 . 12:28 20946711 AGE STOCKTON PAGE 02/02 <br /> GlTY OF STOCKTO � 6 7 9 O <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION <br /> �FOR <br /> i EN/CRjTOACHMENT ON PUBLIC RIGHT-OF-WAY <br /> A plicanfa Name / l !�iieJ+7— <br /> APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions,and all <br /> Address � ? ICtJ�� Pha� ` 7�%a jo wohc must conform to the projeaS approved Storm Water Pollt.rlion <br /> 17-S-Z 1 Prevention Plan or the City of StOCkton Storm Water Pollution <br /> City State,<5?7N-- ZIP_ Prevention Malntenave Stmt Guide.whichever is applicable. <br /> Location of Proposed Word,etc _. y <br /> Ff <br /> �b D Jt/IttG�cS�„ r r / <br /> s <br /> �- -S7 t�___ d fay — — Date <br /> Owner/Don acts dre —._, <br /> Estimating Starting Date I( Completion Date 3 Permit Expiration Date <br /> I (or We)hereby appi�+for an Encroachment Permit to carry out the following work: J __ <br /> if <br /> Al _c <br /> The above)namod swft nt hemby reo"s perm"on to• �?80 0 <br /> PERMIT FEE <br /> Additional Footage Fee........... $Trench Fee - <br /> i <br /> .....$ <br /> I <br /> Sewer Tap Deposit...................$ . <br /> TOTAL DEPOSIT.........$ �— <br /> i <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> AYU 5� Ir-'179r SSG lC #e <br /> 5)"'k f( ,fie emj(auol Fibr <br /> e.sha �tmtc,above or refer to Qlmw ng subrn ved <br /> IMPORTANT: Appr nt hereby agrees to comply with all provisions cf this permit,as well as all applicable City ordinances,rasoltfions, <br /> Standards and Specif7ca' s currently In effect,and to pay to the C ty its actual cost for removal and proper replacement of any item which does <br /> not meet the above requl ments.Failure to comply will because for revocation of permit.Applicant agrees to indem,lfy and hold the CRy <br /> harmless against any an an losses,costs,or damages resulting from injt,ry 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 Rask Manager prior to issuance <br /> of this permit. <br /> PENMITTEE SHALL C (208)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN:cXCESS OF 72 HOURS, <br /> PRIOR TO THE START 9F WORK,AND Pr;IOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE RFVERSE SIDE OF T HI$ <br /> PERMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OFACONTROL NUMBEi9,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND tHE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER,(FOR CAPITAL IIAPRC VEMr-NT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE/.SSIGNED CITY PROJECT ENGINEER Al (209)937-E411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROvI, NS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Y1 <br /> Signed:-- /G a Phonrt: <br /> 1st-i ermltlee(white) 2nd-Inspection(pink) 3rd-Elle(yellow) Mr•Flnance(white) <br />