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Jun 28 O1 04: 20p of StocktcnPW_Permit (2937-8901 " <br /> gRs Esq <br /> S CPfY OF STdEPART 664 9 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Aa-r Q <br /> r r / ._-_._ fYu m..�t Date 1 °f APPROVED:BY THE PUBLIC WORKS DIRECTOR <br /> ,=p ,ants Name. uN Subject to the General PIe`rf510f15 and special Conations,and all <br /> (Oxner(Contractor) c/a tF� 5 to 452-'I-M wads crust confarm to the projects approved storm Water Pollution <br /> (.LTA r l Prone h <br /> Address 11 rib ��o f w Prevention Plan or the Ci 0 Stockton Storm Water PW soon <br /> State CA- ZP 4r1 CO5 Prevention maintain ce Stefi.f�.ricl ,whichever is applicable. <br /> YnErwVt <br /> City j r <br /> �2c Or � Frtrr �_��I� [erit�A' I <br /> Location of Proposed Work,etc. <br /> � T cal JC AVf , <br /> of r�EJA Alk1 }�w7 1/l , �t <br /> Ownedcontraclor Address SAK ~ r— C} <br /> Estimating Starting Date <br /> �3N E 2�1 Complenon Date u �ermlt Explratbn Dale r f <br /> ------- <br /> 1 for an Encroachment Permit to carry out the following work: 3Ntrort oT�en�—� `�D <br /> I(or We)hereby aPP Y <br /> tl/ZC2 V0 'Z <br /> AQ 69/Z C2G l�fi/"inl (Jx r <br /> r- <br /> Tneoeu+rrmae aDpram na.mf r�a�exs Ve^^Iclon ro- PE.4MIT FEE............................S <br /> SIE IV77 Additional Footage Fee............S <br /> �J/ZU6/JS E[7 C/XPT/ut/ �')NG <br /> Trench Pae...............................$ <br /> Sewer Tap Deposit....... <br /> N/ .___..._.5 <br /> f'1 �1�P/GaY- cJEG-� OE.f/GTOTAL DEPOSIT.........S <br /> J 'J Building Permit No. <br /> Improvement Plan No. <br /> Supplemental CcndRions: <br /> �,.Lr. •. r .j <br /> ,trC • k <br /> STOM&YORT eCOW Or mM(OOn�9 YYbitmeq <br /> cam her eas ffl comply with all provisions of This permit.as well as all appEraCle City ordinances,resolutions, <br /> IMPORTANT: Appliebv�r <br /> Slardards and specifications curtentil in etrect,ander Pay II be to the cause f�rets actual cost vocation off permit Applicantoagreesrto'rreplace <br /> demntand hod the of may item which es <br /> not meet the above fequiremenbs.Failure to comply occurringat the site <br /> Risk Manager dor to Issuance <br /> narmiess against any and all losses,costs,or damages restating from injury to persons,doattf of person or damage to property <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the CITy 9 P <br /> of this permit DL NUMBER NO LESS THAN 24 <br /> PRIOR OETSHALL HESTA CALL <br /> L(2T OF 00)937-8366 FOR A <br /> AND PRIOR TO ANY EOUIRED INSPECTIONS.A9 IDENTIFIED ON THE S,BUR NOT IREVERSE SDE OF THN EXCESS OF 72 US <br /> PERMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER.HE CONTROL NUR ECT <br /> MBER WILL <br /> BECOME SUBDIVISION IMPROVEMENTS,PER fTTE SHALL CONTACT HE ASSIGNED CITY PROJECT NIGINEER ATAL OT(2 9)937VEME -84111 FOR OJ OR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF TM.5 PERMIT BEFORE SIGNNG, ��� '�♦ r D:J`� <br /> I kJned Phone <br /> 8 <br /> 1st-Permmee(wrvte) 2nd-kispeclim(pink) <br /> 3rd-File(Yellow) 4NN-Fkrance(wNte) <br />