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Public Works Department <br />City of Lodi Encroachment Permit <br />Application (Construction) <br />Permission is requested to encroach on the City of Lodi's Right of Way as follows: (Complete all <br />items. Use NA, if not applicable. Application is not complete until all required attachments are included.) <br />1. Permit Address or Street Name Church Street <br />2,. Cross Street (Distance and direction from site) Tokay Street (South of Church, approximately 50 ft) <br />Applicant City of Lodi 221 W. Pine St Lodi CA 95241 209-333-6706 <br />Name Address City State Zip Phone No. <br />Contractor Water Rock Construction 2363 Mariner Square Drive, St 243 Alameda, CA 94501 <br />Name Address City State Zip <br />510-671-2095 <br />Office Phone No. <br /> <br />612-655-7977 983523 A,B <br />Cellular Phone No. License No. <br /> <br />Estimated Start Date 09/28/2017 Estimated Completion Date 11/09/2017 <br />Estimated Cost in City Right-of-Way (Excluding material costs) $120,000.00 <br />Work Description (Fully describe work within City's Right-of-Way, including any street or lane closures. <br />Attach separate sheet if necessary. Attach complete plans, specifications, calculations, maps, etc., <br />where applicable.): <br />Installation of extraction well in the road. Southbound bike lane/right hand turning land on Church at Tokay closed for <br />approximately 6 weeks. <br />Additional Information (Check one or more of the following): <br />Er Sidewalk Replacement/ Installation: Length up to 75 Lineal feet Sidewalk Width 5 feet (Excluding curb) <br />0 Driveway Replacement/ Installation (Check one): <br />0 Residential Width Lineal feet <br />Commercial Width Lineal feet <br />Gutter Type (Check one if applicable): <br />0 Square (15" gutter) ISY Vertical (24" gutter) <br />0 Rolled 0 Driveway 0 Other Curb and gutters per City of Lodi STD Plan 135 <br />0 Utility Work <br />EY Excavation 0 Directional Boring El Other Well Installation <br />Max. Depth 2' Avg. Depth 2' Avg. Width 15" Length —65' <br />Surface Type Asphalt/Concrete Conduit: Type PVC Diameter 4" <br />LI Other (Describe): <br />The undersigned agrees to indemnify and save the City of Lodi free and harmless from any liability in accordance with the provisions of <br />Lodi Municipal Code ([MC) Sec. 12.04.040. Permittee is specifically aware of LMC Sec. 12.04.290 thereof relating to the relocation Of <br />removal of said encroachment if future construction requires such relocation. Permit void if work not started within 6 months of permit <br />date. The undersigned agrees and understands that a permit can be denied or a bond required for non-payment of prior or present <br />permit fees, that the work will be done in accordance with City of Lodi rules and regulations subject to inspection and approval. Permit <br />application fees are non-refundable. If the work for which this permit has been issued has not been completed within 6 months of permit <br />date, the City of Lodi shall have the right to complete the work, and to file a Cause of Action to recoup the City's expenses in completing <br />the work and for all other costs and fees in accordance with the provisions of the Lodi Municipal Code Section 12.04.120. <br />DATE SIGNED <br />[ <br />OFFICE USE ONLY PERMIT STATUS: <br />PERMIT NO. °PENDING °FINAL <br />DATE & TIME RECEIVED ODENIED/VVITHDRAVVN <br />FEE <br />Minimum amount (Balance to be collected at permit issuance) <br />TOTAL FEE: <br />EncroachmentPermitApp doc 3/12/2004