HomeMy WebLinkAbout4-Right-of-way Joint-Trench Excavation Permit ApplicationJoint Trench Excavation Permit Application
for work in the City Right-of Way or Easement Page 1 of 2 September 2012
PERMIT NO.
CITY OF LAKE ELMO
3880 Laverne Avenue North
Lake Elmo, Minnesota 55042
Phone: 651.747.3900
RIGHT-OF-WAY OR CITY EASEMENT
JOINT TRENCH EXCAVATION PERMIT APPLICATION
Name and Address of Lead Utility (Permittee): Name and Address of Party Performing Work:
Contact: Contact:
Phone: Phone:
24-Hour Emergency Phone:
Email address:
24-Hour Emergency Phone:
Email address:
1. Utility Type:
(Check all that apply)
Company Name Total Installation
Length (Ft.)
(Column A)
Joint Trench
(Ft.)
(Column B)
Additional
Footage (Ft.)
(Column A–B)
Gas Main
Gas Service
Electric Main
Electric Service
Telephone Main
Telephone
Service
Cable Main
Cable Service
Other
TOTALS:
Line (1) Line (2)
2.Attach Joint Trench installation detail providing surface depths, size and type of pipes, conduits and utilities.
Length of joint trench: Dimensions of excavation:
Line (3)
Joint Trench Excavation Permit Application
for work in the City Right-of Way or Easement Page 2 of 2 September 2012
3. Type of Surface to be Disturbed: Gravel Bituminous Concrete Boulevard
4. Location (House No., Street, Nearest Intersection, Development Name):
(Attach 5 copies of scaled drawings showing accurate right-of-way information, topographic information, and planned installation.)
5. Work to start on or after and to be completed on or before
6. Will detouring of traffic be necessary? Yes No If so, describe routing:
For
(Applicant)
Signed By
Dated
The date when the work is completed must be reported to the City of Lake Elmo.