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L CITY OF STOCKTON v 65251 <br /> 1 DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> /7 <br /> Applicant's Name —4.(Lc�9nrYf <br /> (Owner/Contrattor) /)/ /� J <br /> Address � <br /> AddrcX // P !4 y Phone"4n) 3f(2-5e/p <br /> Location of Proposed work, etc. -/�i/� �j Xu �_• 5 - APPROVED: PUBLIC WORKS DIRECTOR <br /> Owner/Contractor Address By f / �/ Pe ml E p axon Date7 <br /> Da �Estimated Starting Date _ ZCompletion Date -Z �/ <br /> — <br /> I (or We) hereby apply for an encroachment Permit to carr out the followin work : C'�{ <br /> ! p y g --t./11/r in <br /> �rr� I '`o.il BdG� FILL TC7 <br /> s7YYY n PSI <br /> 6'T7bIJ�, <br /> The above named applicant hereby requests permission to <br /> PERMIT FEF... . ..... ,, g <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT ... q I ZR <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> , S�ULD 77fE k)90K <br /> aC-4201ar-- 774E CLj1u12s—r Ccs <br /> A&-4,-( "rP-AkIjEL L4JFc5! ALL C.I42C <br /> SµgLL --&----Zt:ST12lGrf�C '70 NIL-44T <br /> snow sketch.have or refer to araw:ng submitted I.JBQ.k L'L`r / — 40 'L4+x& CtLgUeE.S <br /> !O. - ACL Lajf-�s 494LL <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this pelt as wellas all able City ordinances, resolutions, -'00A-1 <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 (1-800.8-42 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 permit before signing Note of notifications and inspections. <br /> c <br /> S:fined. ._ CC.�i <br /> 1st—Permmee 2nd—File 3rd—Finance/ / — <br /> ✓✓ a^,—UnuFyl Street l <br />