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CITY OFIOPI ENCRUACHMENT PUBLIC WORKS DEPARTM06 ' 221 W. P- INE ST. 333-670AptP. O. Box 3006P R l rT LODI, CALIFORNIA 95241-1 i Permit Address 1 420 So Applicant's Name grown & Caldwell , Attn. Larry E. . hi li s 723 S Street, Sacramento, CA (Owner/Contractor) �ddess Starting Date 6/22/87 Completion date LIC nse No. Phone (916)444 0123 Owner/Contractor Address Phone Pursuant to the provisions of the Lodi Municipal Code,the undersigned applies for permission to excavate.construct,and/or otherwise encroach on City Street Right-of-Way or Easement by performing the following work- NOTIFY USA (800) 642-2444 48 HOURS PRIOR TO ANY EXCAVATION. The work consists of drilling moni'toring' well atWell #12 and installing water tight permanent base. Work to be v• Forkas, Water Superintenden PAYMENT PSE IVSD (333-6740) AUG 18 1998 SAN JOAQUIN COUNTY Obtain permit from Local Neo l th District ENPUBL.10 HEALTH SERVICES VIRONMENTAL HEALTH DfdlBlON (Space For Sketch) = Permit void if work not started within 6 months of permit date. 1:1 Dirt, dust, and mud to be controlled by Permittee or City has the right to do the work and bill Owner. ❑ Certificate of insurance in the owner's name which names the City of Lodi as an Additional Named Insured for Compre- hensive General and Automobile insurance in the amount of $1,000,000 combined single limit is required. The undersigned does hereby agree to indemnify and save the City of Lodi ree and harmless from any liability, in accordance with the provisions of Sec. 12.04.040 of the Lodi Municipal Code.Permittee is specifical y aware of Sec. 12.04.290 thereof relating to the relocation or removal of said encroachment if future construction requires such relocation. If the work for which this encroachment permit has been issued has not been completed by the City LDate f Ldi shall have the right to complete the work,and to file a Cause of Action o recoup the Ci 's expenses in completing the work and for er costs and fees in accordance with the provisions of c. 12.04.120,o the Lodi i i at e. := �7 Signed:: '`' moor reed This p rmit is granted subject to,all provisions.of Chapter 1,2.04 vement of the Lodi Municipal Code, and to.allgeneral provisions and tyapplic ble special provisions as'shown on the`reverse sidef lnsurar�ce' Date !Permit Approved: CITY OF.LODI ed to . F.. ,Forkas By: _ ublic Above Ground Date:, Inspected "Date ❑ Public Underground Completed Date' © Private, to bemaintainedor relocated by owner as required. Reviewed Date �- other Permit No. i I is?-500 7$I-Inspector 2nd-File 3rd-Permillee LODI PRINTING CO-