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CITY Of STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT.ON PUB4IC,RIGHT-4OF-WAY <br /> .. vel Ael(n eo ivlP 2 a� 57"614 <br /> Appllrnnl'e!lame __•—�.--- e — <br /> fee <br /> /c Pin,U11foLb� }}} <br /> n pj h �� - � APPROVED. DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,rte -- <br /> Owner/Confroctor Addreu <br /> Estimated Starling Date. .. 9 rCompirfion Dot ^Permit Expiration Dafa <br /> I (or We) hereby apply for an encrocchment permit to carry out the following work,._ 1�'' 01311ye SrAl tit�Z6110 nr <br /> The obw*named applicant hereby requests permisslars.o- PERMIT FEE.............................................. 5. <br /> G►,C!�Oo. 2553 Add,fiond Foot."Fee...- ..... . <br /> Sewer Top Deposit.................................... <br /> TOTAL DEPOSIT ........................ S <br /> . . . Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: 1Fq rQEdDC1.�GC <br /> • �Ff��/�7/T ��G1/ .. <br /> Slow sketch above or refer to dmwing submitted <br /> IMPORTANT: Applicant hereby agrees to campty with alt Prov€sioris of this permit as well,as al!'appiicabie City ordinances, <br /> resolutions, standards and specifications currently effect,and to pay to City its actual cost for rt:moval and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to Indemnify and hold the City harmless against any and all losses, costs, or Larr.ages resulting from injury to <br /> gid at the site of aF aS Q result of work to be performed under this <br /> persons, death of person or damage to property oacun: <br /> permit, Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions or,roverse side of this permit before slgniny 'Nota.aqui/em tot notifications and Inspections. <br /> Permit Engleeerflnspfactor r <br /> 944.8482 <br /> 944.8313$ Signed. Phone <br /> lit—?ermittes- 2nd-•4ile 3rd--Finance 41h--Utility/Street - - - <br />