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Excavation Permit Application for work in the City Right-of-Way or Easement September 2012 <br />PERMIT NO. <br />CITY OF LAKE ELMO <br />3880 Laverne Avenue North <br />Lake Elmo, Minnesota 55042 <br />Phone: 651.747.3900 <br /> <br />RIGHT-OF-WAY OR CITY EASEMENT <br />EXCAVATION PERMIT APPLICATION <br />Name and Address of Utility Owner: Name and Address of Party Performing Work: <br />Contact: Contact: <br />Phone: Phone: <br />24-Hour Emergency Phone: <br />Email address: <br />24-Hour Emergency Phone: <br />Email address: <br />1. Nature of Work:  Gas Main Telephone Main Cable Main Electric Main <br />Gas Service Telephone Service  Cable Service  Electric Service <br />Other <br />Type of Surface to be Disturbed:  Gravel  Bituminous  Concrete  Boulevard <br />2.Location (House No., Street, Nearest Intersection, Development Name): <br />(Attach 5 copies of scaled drawings showing accurate right-of-way information, topographic information, and planned installation.) <br />3. Size and kind of pipe, conduit or cable: <br />Length of pipe, conduit or cable:Depth from Surface: <br />Dimensions of Excavation: <br />4. Method of Installation or Construction (including method of compaction and excavation) <br />5. Work to start on or after and to be completed on or before <br />6.Will detouring of traffic be necessary?  Yes  No If so, describe routing: <br />For <br />(Applicant) <br />Signed By <br />Dated <br />The date when the work is completed must be reported to the City of Lake Elmo.