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3DVd 1068 LCC 6OZ 6 i ' S T 10 . 91 Sdv <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 Applicant's Name + c.- aM c Date a� 0C' APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> (owner/Contractor) SubleU to the General Provisions and Special Conditions.and all <br /> isrir'ip► S••i z Phone S) work must conform to the prolecrs approved Storm Water Potknion <br /> Address Prevention Plan or the city of Stockton Storm water Pollution <br /> City State-Ca— 71P6 Prevention Maintenance Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc i at/x e� !f - I 1 f! <br /> y ! Llrt0 \YtL rri]a.ahyrt..I 1 ley�t' <br /> t Date <br /> owner/Contractor Address_ <br /> Estimating Data <br /> f oo I Completion Date erroit Expire Date <br /> OHt SGi �'jori rn <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work e � <br /> T Q ro ll l Yrt L LG L. hcr+ <br /> Tho&to,b named apple M 11011111 raquasra P*rn%"M w PERMIT FEE S L <br /> Co pI G fa ce p ry be .5011 R a r•:vis Additional Footage Fee S <br /> -�nIJt7�i Trench Fee $ <br /> 130n r' Sewer Tap Deposit $ + <br /> /�VG. . I�TFtir Pro pix t� <br /> TOTAL DEPOSIT S <br /> - --Loc�.���=,Yoh <br /> (f�,+yy� A v< ����0 Budding Permit Na <br /> Improvement Plan No <br /> ljt�� P Tj't, LU <br /> Supplemental Conditions <br /> sc ` Oa <br /> 1ir M, <br /> ` t'•? �tt;` _� ruJ <br /> �71..a. all ..At�e: 3.uY-xCtr C..uuLl t <br /> Show Wrap atwva or Iaia1 iC daanq"W"ad i rG M r v-aiJ l.�r <br /> IMPORTANT Appacani hereby agrees to comply with all proweione 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 removaldproper treplacement <br /> pilacemei fyandfany Item the m�does <br /> not most the above requirements Failure to comply will be cause for revocation of permil Applicant9 any and elf lasses, occurring at the site <br /> harmless asatrisl acosts or damages resulting from Injury to persons,death of person or damage to property <br /> t.A certdicate Of Insurance shall be submitted to the City Risk Manager prior to issuance <br /> of or es a resint a wank to be performedcost under this perrnt <br /> of this perrruL LESS THAN <br /> 4 HOURS.BUT <br /> PER R TO THE TART OF�WORK.A DBPRIOR TOANY A OUIRED NSPECTIONS S2 IDENTIFIED N The NOT IN EXCESS IIHOURSF 72 <br /> FOR A REV RSE SIDE OF TTS <br /> PRIG <br /> PERMIT IF WORK DO <br /> E&NOT BEGIN WITHIN 72 HOURS QF THE lSSUANC£OF A CONTROL CAPI AL THE CONTROL IMPROVEMENTPROBER ER <br /> BECOMEROL NUMBER (FORSAND <br /> THE <br /> E PE PEREE SHALL E SHALL FORA NEW CONT THE ASSIGNED G PROD CT ENGINEER AT(209)937.84111 FOR ECTS OR <br /> SCT SIO N 1MP <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS P RMIT EFORE SIGNI �� <br /> stpuld Phan _._ -e k)i -1 <br /> tsl PermEttee(while) <br /> 2nd Inspection(pink) 3rd-11I tyeIIOI 4th-Finance(while) <br /> 'd 2068-LE6 [6I]Z] %sruJad-F1dUQ-4M0o'4S JO R%iO dS2 :ED ZD 91 .add <br />