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521 <br /> • CITY OF STOCKTON • 6 <br /> DEPARTMENT OF PUBLIC WORKS <br /> A9# APPLICATION FOR ENCRCACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants <br /> (Ownerl ntra o <br /> Address '"L �4.+-L %.�z 5... .. �a Phone 14S)79L-5110)' <br /> i,,I ,,,)o, CO, q'Ill 4ry APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> Owned Contractor Address f • e,A, -- B Date 1 <br /> Estimated Stag Date 1 I7.le �Q�l Completion Date �OtR Permit Expiration Date � /' LJ <br /> (or We) hereby apply for an encroachment permit to carry out the following work: 1 'z—NA I A; tzaa)z� <br /> t <br /> PlL-(1Flc_ rfA_ is xk GF <br /> C L J <br /> GP <br /> �I LLQ M3 \G Ill.. tot,) la 1 Ml�l \°I cn' , Lo �R' <br /> �t <br /> The an"named applicant hereby requests permission to- PERMIT FEE. $ <br /> IfS Additional Footage Fee............. <br /> Sewer Tap Deposit ................ <br /> 'r-S{ WELL TOTAL DEPOSIT......... 5 1 <br /> Building Permit No. <br /> Improvement Plan No. <br /> SOV C?Ji-S( C1e�,2 Cil Supplemental Conditions: <br /> 4u L= C '�iJ-Q�SL CHS CIS Su CE <br /> 6- <br /> Show sketch atw a or reler to drawing submineE (C) •LLQ ��� ��� � 1— ��` � <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1.800-849.2444) 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 and inspections. <br /> r _ _ <br /> Sg:eo: <br /> Phone <br /> 1st—Permittee 2nd—Fila 3rd—Finance 411,—Utilityl5lreet _ <br />