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q7�7- <br /> CITY OF STOCKTON4 <br /> 8 <br /> PUBLIC WORKS DEPARTMENT �� P?'? G— ZZ '[y� <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Appplicant's Name E - R Q Date 1 . 17- oz APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> (OwnerlContractor) Subject to the General Provisions and Special Conditions,and all <br /> Address 1 LID 6,01d1-76 Phone ill-63 f- 1500 work must conform to the project's approved Storm Water Pollution <br /> L.rdOra. State C BP 9 5 6?o Prevention Plan or the City of Stockton Storm Water Pollution <br /> City Q ,ti • Prevention Maintenanc Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc 308 I�. i �+► �� <br /> C. M r 1f <br /> Owner/Contractor Address B DateEstimating Starting Date 2 I I 0 Z Completion Date 2 D tt Expiration Date -1115 d�- <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work l <br /> a an n <br /> The above narned appucant hereby requests permission to PERMIT FEE $ <br /> Additional Footage Fee $ <br /> Trench Fee - $ <br /> Sewer Tap Deposit $ <br /> TOTAL DEPOSIT $ <br /> Building Permd No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> i <br /> W ND iastii G�osoY�S att �1GIrrA+i`k� f�1f�i. <br /> pY°j tc t✓ <br /> 1 a cams <br /> Show sketch above or refer to drawing submitted 1'I;JCId) � f,(M rl. <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 beCALerformed under this permit A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. O 9 ®A — c���t 0 T68, 9r "04 <br /> PERMITTEE SHALL L(209)937-8366 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 /> ERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> 0ECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> - 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 TH RM EFO SIGNING. <br /> Signed <br /> Phone <br /> I st-Permittee(white) 2nd-Inspection(pink) 4th-Finance(whRe) <br /> pink) 3rd le(yolk,,) <br />