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CITY 0' CAKPHELL
D~PT. or VUbLIC WOkKS
70 ~octh Ilr.t it.
Campbell, CA '~OOM
1.0& I IIh-21 ~O
88-'114
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PUIILIC WORKS .i:RMIT
Tf1rr'""1IOYn11'i) I n t n e
p~bl1c cI~ht-ot-waY)
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P.c.It No.
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Applicatlon Oat. (~~/~. (phone)
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APPLICATION - Applicatlon ia her.by .ad. for a P~bllc Work. 'aralt In accordance wIth Ca~~bell
Kuniclpal Code, iection 11.0..
'Cl
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l. WOCk addre.. or tract .
Utillty trench locatlon
Intersection of Latimer & Central
(N W CofCAjE~ - N :..s
P.
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It. Nat~r. ot wock; .
Uncover and repair 2 gate valves
c.
Attach tiv. I~l copi.. of a drawing Ihowln~ tbe locatlon, ..tent and di.en.lon. ot the work
The drawin9 .nall .how thl rel.tlon of the propo.ad work to exi.ting .urtaca and underground
improvement.. When approved by the Clty Engineer, .ald drawing becom.. a part of th1. per.lt.
The General Condltlon. tor all permitl are liatad on the rev.rae .1de. SpeCial Provialon. tor
thi. per~it arc li.tcd below. ~ailure to abide by theae condItion. And provl8iona a4Y ccault
in 10b ahut-down and/or forte1t~re of Faithful PertormAnce bonde and caah depoelu.. ISee
GOfleral Condition. land 21.
~. An applicAtlon tee mUlt accompany this application. Thia 1. non-rufundable.
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Name of Applicant
Addre,,"
li thi. wock bcin9 done 'by the property owner at theic own ulildencd _yea no
SAN JOSE WATER CO
Te lcphona :'-, "'Cot. -"~'z.. "S"
Complete attach.d Workec.' Compenaation and Contractor loc...
The Appllcallt/~ecmittce hereby agca.. by attlxing their Ilgnature to thi. permit to hold the CIty ot
Call1Pbell, itli otticeC/., agent. and ulployeea tree, liate and haraleali teom any clalll' or demAnd tor
dA"'Age. reaultlll':l trolll the work coverad by thie perll.1t.
The AppllC4nt/P"r..lttce hereby aCknowledgeli that they hAve reAd and un()eruAnd both the tront and
baCk of thi.1i peCluLt aftd that they wIll inform thell contractorllil ot the informAtion.
ACCt:PTt:D
KPPlICant \recwlttee,
lilt e
NOT~S: ALL 'WORK SUALL CONrONH WITII Tilt A'M'AC/lED, APPNOlltD PLAtlS AND ALL APPLICAbLt: CAKPIit::LL
STANDARD DHAWINGS AND CONDITION~.
Tilt: CONTNAC1'OR HUST IIAVI:: TillS PLNHIT AND APPROVED PLAHS AHD HUST Ht:I::T WITH THt: P.W. IN~PI::Croj( ON
Tilt: SITE AT L1:A~T 'I'WO DAY!; HHO~t: STAJtTIHG WORK.
HOT ICE HU$T Ut: GIV1:H TO PUbLIC WORKS AT LEAST 24 /lOURS bEFORE Rt:START1HG ANV WORK.
SPECIAL PROVISIONS
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Strl:~t IihAll not be open c~t for underground Inlit411ationli. H1nlllulll cut. IIlAY be Allo.."d
tor connections or ckploratlon hole~. Such Cutli muut be upecltlCallv bpproved by [he
I IIlopeCt ur.
PaVlm~.AY be cut for undecground 1nutAllation6 and ..uat be re.tored In aCCOcdancc Wlth
thl! Ut1lity Trt:nch ~C:litor4t Ion Standard DrAwing.
Wurk to Oe ataked bV a 11ccnlied LAnd Surveyor 01 Clvl1 Engineer and two 121 copie~ of the
cut eheel# uelll to the Public Work Dept. before atarting work.
The houra ot work Arc lImited to o~tliide the hour. of 7-9 A.m. and l-~ p.m. tor AllY work
attecting a (cAftlc lana.
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PERMIT A~PLICATIOtl rt:K
PLAN CHECK DEPOSIT
OONO t'0j( I'AITllfUL PEkl'ORKANCE
01-1 )
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STAHDAkO
AMOUHT
kI::C~IPT NO.
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1'. P. (CASU) DEPOSIT
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(~2001 C., Ot' BOND.~~OO KINl
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APPROVED I'OR lSSUANC~
f: PWPt:NHIT
k.lli..d 7//J7
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21937
e fa
SJW SURFACING REPORT
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CITY ~ _ (. f"t";; r. !', '.......
PERMIT t'R- II <I
CONTRACTOR =E"~lvl( r
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S.I.O. or EST. No. 76/ OC)
SJ No. 25388
I
DATE ..2.. /~ 9 / :Jg
CONTRACTOR
FOREMAN
SJW '- -n.7
INSPECTOR ,"-.! '-
PURCHASE ORDER No.
LOCATION
1 '
LPi- i r"r",e II' ~ \::
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DESCRIPTION
(SHOW SIZE. STREET
NAME. LOCATION &
SHOW NORTH BY I
AN ARROW.) ~
L,E.'-.j+ f2.6l
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ACO CONCRETE 0
DEPTH IN ----
INCHES <a
~ (AC) (CONCRETE)
~ OIL & SCREEN 0 TAMPING 0
,
---.... (OTHER)
, -.. NEW CONSTRUCTION 0
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ROCK 0
(ROCK)
o
MAINTENANCE
y.fv'\,2.l\'6
l'-X-_ (:. G, - G - 2..
o
SURFACING CREW FOREMAN
DATE
FORM 55e - REV. 5.86