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A <br /> S CITY OF STOCKTON �./ 68309 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATfON FO E�ICROACHM NT ON PUBLIC RIGHT-OF-WAY <br /> -c-,r_r Enc>:r-orlon q 6'�IS o�( <br /> Applicant's Name l't�c=, A11VA"'n Date Il (0 03 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> / Subject to the General Provisions and Special Conditions,and all <br /> Address Z �' T-�r"' :n3 S-'1�eH Phon 435- work must conform to the project's approved Storrs Water Pollution <br /> city .,p tv�0State C Q zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> / f� // Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposelld��Work,etc.�]!/YbG/(U�r [-1-1-' C'C�r�r �Q� `�� <br /> erl <br /> Owner/Contractor AddressG cISO Rmo( A4W4! By 4 <br /> c 553 <br /> Estimating Starting Date V�xn o�,Complefion Date a� r Permit Expiration Date —• —O <br /> I (or We) hereby apply for an Encroachment Pe mit to carry out the following work: 440 a_ 3 c):,-1 S •( <br /> ;n 59-zo 3 se -zz rn S o o-� <br /> 5-�r-t..a-( Rr- ok 0, $ <br /> 41-2 3u - A„�:�;t�L ter—/•o� �a�tA cloy . .t-fo{o�'4 <br /> Sia-z <br /> The above nametl applicant hereby requests permission to- Z 3O Os <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ P <br /> Sewer Tap Deposit.................... $ <br /> OZ <br /> TOTAL DEPOSIT......... <br /> Project No. T 1 Building Permit No. <br /> PPT PF BF Improvement Plan No. <br /> Supplemental Conditions: A <br /> Ah y J��"'Cw�ta��J/rNoJ �OrIS S�k�l// 6C <br /> All VSA rr. /khr�r Jfh•t[I rje�tnwvr.��I°s�L <br /> C.+/[iNbnoL won[C <br /> Shaw skerM above or refer to tlrawinp submittetl <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 the City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> 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 <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEES LL CALL(209)937-8366DFORAONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIORTOTHE RT OF WORK,AND P ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK D (THIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFOREFO'/ SIGNING. -t C --/ <br /> Signed: X/ `--tl� lam Phone: 6TOq� <br /> 1st-Permittee(while) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />