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it <br /> CITY OF STOCKTON 67880 <br /> PUBLIC WORKS DEPARTMENT <br /> ii APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant me Adyiiiinced cl Egt1Vi itiniwttl ate 7 1 03 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner o a ) Subject to the General Provisions and Special Conditions, and all <br /> AddressY37 ha ilac Phoney ri 9 �t I7 �� work must conform to the projects approved Storm Water Pollution <br /> city es7 �Ci P �l 17JI { State l FT zip SZ 1 S Prevention Plan or the City of Stockton Storm Water Pollution <br /> .r Prevention Maintenance Stat Guide, whichever is applicable. <br /> Location of Proposed Work, etc. rYbd UARE7ct Vct_ <br /> Vel 5#re � � . 5r�fk ckf lcsr iii ![/j <br /> Owner Contac Address g 7 �.6 ;,8, _��(�S Gi+L 6A.1 CA- 11 AV4i Date <br /> Estimating Starting Date e,j 0--3 Completion Date Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 7,7a4-gl! <br /> nf4T3lrn rrA12541 A4n. 1es <br /> r <br /> AJ HIDA) C-c r S.4r eZ44 )X <br /> The above named applicant hereby requests permission to - Z3© W <br /> yy /� PERMIT FEE ................ ...... $ �— <br /> fikA W rep /e r, A0 Q 1 G, `a ., al / Additional Footage Fee .._........ $ c/ <br /> !!! �C T p �`z-,C Trench Fee ............. .................. $ <br /> Dpi Gal Sl1p <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIITT ..,.,..... $ 03, <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> AI <br /> Show sketch above or rotor to drawing submitted <br /> l <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 /> PERMITTEE SHALL CALL (209) 937-6366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 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 SIZE OF THIS PERMIT BEFORE SIGNING, <br /> Slgnnd• Phans: <br /> 1st-Pennittee (while) 2nd-Inspection (pink) 3rd-File (yellow) 4th-Finance (white) - <br />