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s <br /> ® CITY OF STOCKTON "' FO <br /> nDEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAYJAN 0 5 1999 <br /> rorru" AAY Cca rw„vc !/t`FM'-a q y" - I .aLI I-I <br /> Applicant's Name LAc --LNL _ - Date�_��1_r <br /> (Owner/Contrac �1� <br /> Address /9-N6�ny/zlwfL�- Jr-, �L � -- Phone 06 "Z yf DO <br /> Location o1 EposeQ Work,era CoYy6,08 6tJ�0^� �AV APPROVED: PUBLIC WORKS DIRECTOR <br /> A/fo2 7JUP AAJro¢sSzw*u er 1f61A,'an/ IIIA Ad, fELrd.L✓,a, <br /> Owner/Contractor Address I./Sff df[.o+�l * B Date <br /> Estimated Starting Date ..J `E/ T 9 Completion Dale Permit Expiration Date _-2 A <br /> (or We) hereby apply for an encroachment permit to carry out the following work <br /> "X7M t 10" OF ON,E -TO/L . M"A 7W 1fi%W Aj42Z ' IVO Z—IN[// 10M eTX/L Sty /elL,t,Z <br /> Syecavrnvcroc ' 6/�f6� Iiry TA,c 4Sn f/owF Ie0 �errilurt, CA 93557 <br /> The above named applicant hereby requests permission to- PERMIT FEE. $ <br /> Additional Footage Fee............. <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT......... <br /> L6 U714"' 23 / Gam' Building Permit No. <br /> Improvement Plan No. <br /> �dvaf Ar7ou,�EO Supplemental Conditions: <br /> ��- p I <br /> g°g ;, <br /> Show,sketch above or refer to drawing submitted <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 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. &41- <br /> PERMITTEE <br /> a2PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800442-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 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 requirement of notifications andel/inspections. <br /> SigneB. - � Phone. !q <br /> /O - _91S <br /> 1st—Permillee 2nd—File - \ 3rd—Finance dth—Utilityl Street <br />