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Application for Encroachment Permit <br />ENGINEERING DEPARTMENT Date of Application <br />Phone 925 931-5650 Email eod@cityofpleasantonca.gov Date Work to Begin <br />Date of Completion <br />Work Location APN# <br />Owner/Developer Phone <br />Address: <br />Contractor:Phone <br />Address: <br />California Contractor’s License # Type Exp. Date <br />Workers’Comp. Carrier Policy #Exp. Date _____ <br />City of Pleasanton Business License # Exp. Date <br />Valuation of Work in the Right of Way <br />Description of proposed work <br />REQUIRED:3 copies of the Plans for proposed work (Google overview map with sketch showing work at <br />minimum), traffic control plan (allow 48 hrs for approval), copy of liability insurance with endorsements for: <br />1) naming City of Pleasanton as an additional insured, and 2) waiver of subrogation. <br />The undersigned hereby certifies that all work proposed herein will be completed in a timely manner to the <br />satisfaction of the City Engineer in accordance with the provisions of Chapter 13.04 of City of Pleasanton’s <br />Muni Code and City Standards. <br />Sign _ <br />Date Title <br />Print _________________________________________ <br />Application reviewed by Date Permit Number <br />Observations/Special Conditions <br />Bond amount required Cash Surety <br />Permit approved for issuance as noted above: <br />By Date <br />X:\Engineering\Forms And Guidelines\Encroachment Permit Application.Docx <br /> <br />The Liberty Company Insurance Brokers <br />(530) 228 - 1928 <br />Code and City Standards. <br />_ <br />Justin Brandon <br /> <br />2025 <br />2025 <br />+DQVHQ'ULYH3OHDVDQWRQ&$ <br />City of Pleasanton (925) 931-5519 <br />PO Box 520, Pleasanton, Ca <br />Well Industries Inc. <br />3282 Hwy 32, Chico, Ca 95973 <br />812678 C-57 7-31-2025 <br />7600019873251 1/1/26 <br />1023975 1/28/2026 <br />$50k <br />Test well development and testing <br />/2025 Project Manager