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CITY OF STOCKTON DEPARTMENT OF`PUBLIC WORKS APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-O&WAY r Applicants Nome Western Geo-Eng' Date `57641 e Addresssstont`«r $earner, St. , WoodPhone land CA (916)562-454 Address._ � Location of Proposed Work,etc Pacific Ave. & Douglas Road. APPROVED DIRECTOR OF PUBLIC WORKS _ _ - Owner/[ontroctor Address By Dote Estimated Starting Date Completion Date - Permit Expiration Date I (or We) hereby apply for an encroachment permit to carry out the following work Pacific. Avenge in the vicinity of Douglas Road in accordance with Construct and maintain three -groundwater monitoring wells on theside of _ east „ _ Revocable Permit #89-01 . The above named applicant hereby requests permission to PERMIT FEE S pre a i d Addithonoi Footage Fee _ Sewer Tap Deposit TOTAL DEPOSIT a s Prepaid Building Permit No Improvement Plan No _ Supplemental Conditions As stated in Revocable Permit No. 89-01 t Show sketch above or refer to drawing submitted IMPORTANT Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, standards and specifications currently in effect, and to pay to City Its actual cost for removal and proper replace- ment of any item which does not meet above requirements Failure to comply will be cause for revocation of permit Appli- cant 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 Certificate of insurdnce will be presented by applicant upon request- Read General Provisions on reverse side of this permit before signing `Note requirement of notifications and Inspections Permit Engineer/Inspector 9448482 ' 944•$366 signed, Phone i st—permittee 2nd-.-4tte 3rd—Finance 4th—utihty/street