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Jun 28 01 04: 20p City of StacktonPW-Permit (209)937-88901 p. 5 <br /> • CRY OF STOCKTON • �S � <br /> PUBLIC WORKS DEPARTMENT 664 9 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> (� Cif <br /> � <br /> Ap11Cgs NameJ(-rrLrNt t[Farr DFF[�rop.To Date„�_ t ' p i APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> lownar7Contractor) c16 z-e - Subject to the General Provisions and Special Conditions,and all <br /> Address (90) fs-4fu- JAS _�1T '- __Phone S.la t5�-ESDI) work must conform to the projects approved Storm Water Pollution <br /> City + vILL4- -__State Zip 9 CDS-. Prevention Plan or the City of Stockton Storm Water PollutionMai,,a m �uide,whichever is applicable. <br /> Location of Proposed Work,etc. �¢v.t..._=2 F_� W <br /> oP C+-if v'ltk; -Lie A-j) -7rm -Fww0 kt <br /> Owned Contractor Address ;A+•t - <br /> Es9mabng Starting Date +k1_ 2�► Com riedan Date It Expiration Data <br /> I(or We) hereby apply for an Encroachment Permit to carry out the following work: -7Nrr 9A7Y ni Oho <br /> Fi2ov,✓4A/.a7F2 N7o..�,�ovr-'L w6C4J <br /> 40 r-A 1/6 ' IV A;,!4 "! zWi z AIA) L(1:2 7-- <br /> �LL[=yil�K7,A 15YtFr✓t/Z= �.- _-- <br /> Theahwe rumen appirant hereEy npuaxa permissim w- G� <br /> PERMITFEE....................... � <br /> SC-F .An�Ctl�d7 F/GUrcF <br /> / Additional Footage Fee $ <br /> ( 1 /�/LU6U3 fol UKPT/cvV �I'i°7o Trench Fee........................ $ <br /> Sewer Tap Deposit...... _ $ _ <br /> CC 11 TOTAL DEPOSIT.........$ L l � <br /> Building Permit No. _ <br /> Ot / <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> i <br /> Jnow sxeOG�aW'n«inter lotln+Mea suemNoO <br /> IMPORTANT: Applicant hereby agrees to comply with eN provisions of this permit,as well as all applicable City ordinances,resolutions, <br /> Standards and Specificanons currently in effect,and to pay to the City Its actual cast for removal and proper replacement of airy item which does <br /> not meet the above requirements,Failure to comply will be cause for revocation of permit Applicant 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 or damage to property occurring at into site <br /> of,er a i a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to Issuance <br /> of this permit <br /> PERMITTEE SHALL CALL(209)937-6366 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 /> 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 FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTFiUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed! Phone <br /> 1st-Peonmee(write) 2nd-Inspection(pink) 3N-Fda(yellow) 4th-Finance(wNte) <br />