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,0 5, o - <br /> 4- <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT `'L I U O <br /> MM57W <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> co441s'416�ci��7^ <br /> plicant's IeO r G t'� <br /> U Date r 7 6 O 2 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> _ oS'5 Subject to the General Provisions and Special Conditions,and all <br /> Address Z 4 T7 Poi?-f L✓R(` Ie�- Phon�CS O)d/lz�'r work must conform to the project's approved Storm Water Pollution <br /> o <br /> L Prevention Plan or the O of Stockton Storm Water Pollution <br /> City State �L_ Zip Vy _ <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> C7 fC 1r!/.�/r/� . 1�d'C . S, ,CIA//t7% �/C�/r�rr-gip__ �7 <br /> Owner/ ontra Address V ��o�C/� ,237 6 x 1�+��G/ �I_ r/` y1, Ak1%,"ea <br /> Estimating Starting Date 1--y 3110 Z Completion Date 13110..z- Permit Epiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: _ <br /> a r3Tf�i N 570/1- S . &-y USS Av 6 A <br /> P/ 4 L 7'e R !01 i2 r c '7- IDy s H ! x��.�r c= T R �'i2 01--s - <br /> rf�f= CoN'IlP41iC (`ore ON 7`#15 IoS cvic_..& V/ f 0NCX <br /> T--z/9 r lwG' /7 11c <br /> IL <br /> c / Ire AbOVS named 4DP11Cent W80y(equeale 1)81`111148101)W J ar <br /> 1 JW 9/ f PERMIT FEE............................$ / <br /> G J Z I5 17 Additional Footage Fee............$ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT._ ._.$ / <br /> ti <br /> ti Building Permit No. <br /> k <br /> ' 1 \sl.r-` Improvement Plan No. _ <br /> \� Supplemental Conditions' <br /> v t^/o/►k 0, Il gca' ozone /"I fhe <br /> Q <br /> Ji�E?wP., 1 ik Anx QOtMajaw,.a <br /> sti,w 8G rcA'ft---e4 <br /> Show sketch above or rotor to drawing eubmMeu I/ T� _/( rc <br /> -- Vp'i f�6" a l�n� <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this pe t,as well as all applicable City ordinances,resolutions, <br /> Standards and Specifications currently In effect,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.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 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 issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)837-8366 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 INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF HIS RMIT BEFORE SIGNING. <br /> Signed, � Priori : <br /> mer-Perrnin9e(white) na•I tion(pink) 3rcT,FuB(yellow) 41h-Flnerxe(while)117 Q'r L J <br />