ENC2011-00092Print Form
CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OF PUBLIC WORKS (for working within the public
70 North Fkst Strut right-of-way)
Campbell, CA 95008 Issued Q~~ ~ /
Ph. (408)866-2150
Fx. (408) 376-0958 G ~
Permit Expiration Date O
Permit No~ C. ZO ~ ~ ' Gd ~ q ~,
X-Ref. File
Application Date Hoix/o+1 r gY4Kf /g,~D//
Application Expiration Da~~
APN 4 /2 ~ 05- 045
APPLKATK)N - Applkation is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
A. work Addressor Tract No.: ~65 East Rincon Avenue. Campbell, California 95008
utility Trench Location: Iln front of the property under the street. Trench will be 10' long, 3' wide, 6' deep.
s. Nature of work Replace the last 10 feet of the lateral, including the lateral connection to the main.
C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved
by the City Engineer, said plan becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result
in job shutdown and/or forfeiture of faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before
starting work. Notice must be given to Publ'K Works at least 24 hours before restarting any work.
Name of Applicant: Jorge Picado (West Valley Sanitation District) Telephone: (408) 378-2407
Address: 100 East Sunnyoaks Avenue. Campbell, California 95008
E-Mail Address: picado@westvalleysan.org 24-HOUR EMERGENCY PHONE NUMBER: (408) 828-1949
is this work being done by the property owners at their own residence? r YES r NO
The ApplkanVPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe
and harmless from any claim or demand for damages resulting from the work covered by this permit.
The ApplkanVPermittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applkant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way.
Accepted: 1.t~6sf a/l n • lo,, DIS7~i~cf s .Gcgdo /t16r1Qr Sl/5~zoll
(Applicant Permittee) (sign) / Date
paci~i~ lJixidprornd Cdrrs~iya>tidh tgi// Ms~ioty Mom. , 9~/5`~011
(Contractor) (Print Name) Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts maybe
tally approved by the Inspector r?rfor to cutting.
2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
'A",unless otherwise approved by the Engineer.
3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and
the inquiry identification number has been entered hereon. USA Phone: i-800-227-2600. USA TICKET NO.
S. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded.
6. Public Notification Requirements:
7. __
SEE PUBLK WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO.
PERMIT APPLKATION FEE $ 3 6O ~?
PLAN CHECK DEPOSIT $
SECURITY FOR fARHFUI PERFORMANCEMBOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $ _
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE _ ~ ~~~ ~
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
I. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City
ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee.
2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the Cfry.
3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work
by the Ciry.
4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing
to the Permittee.
5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves.
6. A Construction Traffk Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be
reviewed and approved prior to any lane closures.
7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated
1990, available at Caltrans. Traffic control equipment shall include Type II Bashing arrow signs if required.
8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with Ciry Standards and Specifications at the sole
expense of the Permittee.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements.
10. Prior approval of inspector is required for any work done aher normal working hours, on weekends or holidays and may require reimbursement of
inspection costs at the current overtime rate.
11. Adequate signing and barrkading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing
and barrkades and charging the cost (including all labor and materials) against the cash deposit.
12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or
Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m.
14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a
hazardous condition to the public.
15. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a
separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw.
16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
t fl. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the munkipal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTKES established by the Santa Clara Valley Urban Runoff
Poilutbn Prevention Program.
20. If the publk interest requires a modification of, or a departure from the plans and specifications, the Ciry shall have the authority to require or approve
any modification or departure and to specify the manner in which the same is to be made for Ciry-owned or maintained facilities.
21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior
to distribution and include dates of work and a contact name and phone number.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
W6ffi
Applicant
Hannay , ~rsf /S i !~//
Date:
Pactir7 Uiu/sr9ruy~d Co ~st5yclio•~ Mb•f~ynr,~, Atrgvsf /5 ~ ~i~ .
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.09/10
Cabral Graphic Report of 26856
Main Lune
For wvsd
~ Job Number 10-1043 Contract Media aAt getup 3
Operator PANELLI Van Ref 59 Surveyed On 08/18/2010
gtrNt 65 E.RINCON AVE. City CAMPBELL
Survey Purpose IN HOUSE REQUEST
Commenb
Surface VNsather Dry Direction Downstream
Use Sanitary Length 34.3 Ft Entry Potnt Clean Out
Shape Sb:e by 4 ins Condkion
Mabrial VITRIFIED CLAY PIPE Num Taps 0 Tap Loc 0 Pips l>et
Lining Year Laid Joint Type Result
0.0 Ft
Water level 0
0 Ft
2.8 Ft SLACK TO uIYF CC)NNFCl"[OM
24.2 Ft Broken Pipe 12 o'clock [BAD JOINT]
26.4 Ft Separated Joint
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2
m
O
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34.3 Ft
28.4 Ft Crack circumferential 09 to 03 o'clock
31.2 Ft Offset Joint [SEVERE]
32.7 Ft Offset Joint
34.3 Ft Fi~r.~>t~ •.f `!~;~-~ v
J~p~~
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VWSD Phone: 408-378-2407 Fax: 408-384-1821 Pags 1 of 1
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