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CITY OF STOCKTON <br /> V� DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 6ppiLica <br /> nt's Name S ���v 'L� - Date-/J--: <br /> Owner onva r) (li+ <br /> Address O• 56/ 7y ��1111ane <br /> Location of Proposed Work, etc. <br /> r'I APPROVED: PUBLIC WORKS DIRECTOR <br /> 2zu� i�c,;.rxi izTci pv __ �/ <br /> Owne Contractor dress S:O 1tv J S-6 z'_ By Z2Cate h b <br /> Estimated Starting Date ZZ 'Z�- S` Completion Date ��- ��S" P --i Permit Expiration Date _� `-3 1 7 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work -. plac z G f 404 t VACV yii (" <br /> Soilg iie 4ve + arm ¢. ¢ <br /> 1 I ha u oeewetit U alit CE'Hr i t ` a <br /> 4 aa <br /> 9 Z?X- /'6 <br /> The above named applicant hereby requests permission to- PERMIT FEE. . ..... <br /> 1 / <br /> P�Q�^ �`GC N�C� Additional Footage Fee.... . ..... <br /> fccr- ��rL'o—, p F [AO1/e5. Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT. ....... G- _.)C <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <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 City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs,or damages resulting from injury to persons, death of person or damage to property <br /> occuring 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 <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permi efor ignin — N to requirement of notifications and inspections. <br /> signed, _ _ .... --- -- - - PhorL <br /> �/_ J�/�:���� <br /> 1St—Permittee 2nd--File 3rd---Financv 41h—Uhlity f 5treel <br />