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OCT 26 101 11:03 FR LF VINE FRICKE 510 652 2703 TO 1683433 P.02i07 <br /> Oct 25 01 10: 20a of SLOCktonPW-Permit 12 37-8901 t'• 2 <br /> . r , 0028059 <br /> ov2$olA3 V-J <br /> 00zBobynl-3f <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENTas <br /> 66 65� <br /> M05 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAV <br /> (Iua.nJ Cswrrer. Carvrna+�.•wr�4 l2tr+�t�MrttN rti+sT <br /> gqpppliaMs Narnec/a LiluWN- faacr.- Data�l r_•L�al APPROVED:BY THE PUBLIC WORKS DIRECTOR <br /> (Ov cf/Contractor) <br /> 11 6 Subject to the General Provisions and Spectral Cordtions,and ail <br /> Address WAD P weaa.. ST, I Z Phone SIe SL• 4500 work must conform to the project's approved Stone Water Po9utlon <br /> city Sate U• yp 91Lm Provandon Plan or the Dry of Stacktan Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichoveris applicable. <br /> Location of Proposed Work etc.1(BAIrYyL 1+rATldIK otl '�ry4LE+-wd <br /> Owner/Contractor Address SAME y.� l b'ar/e ,�•rl -+-�-�� <br /> Estimating Starting Data SNTg, UA 2i 1 Comple9On Data i rml[Expvatlon Date _`7` - /`� <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> of WrrNiN Vt{ AvAA*4 L4011-1 <br /> OW /0f'rA4A!- <br /> Tha above r d apoml hereby Maw.,,pbmiWon la <br /> PERMIT FEE............................5 2ZS f <br /> AOtlitlonal Footage Fee_..........$ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit....................$ <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> 1 Supplemental Conditions: <br /> Nom ' <br /> Z� u^ clvtt/ S �t.t..i�IL C�L1lr{rYi1CI <br /> u� . <br /> 6hbw ybtd�above ar,aiar ra bev�no�uamtaad <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 affect,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 Applieant agrees to Indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from Injury to persons,death of person er damage m 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 Issuanca <br /> of this panni! <br /> PERMITTEE SHALL CALL(209)937-M86 FOR ACONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PPJOR 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 FORA NEW CONTROL NUMBER(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACTT14EASSIGNED CITY PROJECT ENGINEER AT(2o9)937.9411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Slonod: �/``- --`�� 516 652V..fPO <br /> OCT 25 '01 10:43 209 937 8901 PRG2.62 <br />