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CITY OF STOCKTON 6 7 i l 7 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> lYtdr G Lt t ii _(.Q�. <br /> t <br /> Applicant's Name — Date -710 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) ^ n f C. (lam Subject to the General Provisions and Special Conditions,and all <br /> Address Phone work must conform to the project's approved Storm Water Pollution <br /> City Sta Zip �— "9Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. Sf <br /> Owner/Contractor Address fN / 1 By Date <br /> Estimating Starting Date Completion Date ( pi <br /> A- 2 (� Z � a Permit Expiration Date �L• �5 ��'L <br /> I (or We) hereby apply for an Encroachment Permit to carry out he following work: S,2- E"V��-' <br /> r <br /> ailol <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................$ <br /> Additional Footage Fee ............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ I <br /> Building Permit No. - <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <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 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)937-8366 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 SID F THIS PERMIT BEFORE IG G. <br /> Signed: <br /> - : llzpf-101-3�2� <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-Fite(ye w) 4th-Finance(white) <br />