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vlfARMON070K, (,[JNT% PUBLiC @fL()rKS D5PAlFTMEK"T <br />911112 .9 3f 91660 Myeron Road Ncrth a Stillwater, Minnesota 55052 <br />TL17 yT <br />Phone: (651) 430-;313 o Far: (659) <430-4365 <br />APPLOCAT90W FOR <br />STREET OR CSRWEWNY ACCESS PERG§41i T <br />Attach a drawing of the property, present and proposed access and relation to the county road and any <br />Permit No. ter" �gy <br />CSAHICR <br />Right -of -Way <br />Municipality <br />Storm Sewer <br />Permit Fee <br />iicani Address (Street, City, Zip) <br />Tel. <br />pTel. <br />/d1') `y . <br />Property Owners Address (Street, City, Zip) Tel. <br />Legal Description of Property (abbreviate if necessary) and Street Address: <br />Purpose of ❑Street <br />Access: ❑Commercial <br />❑Field Entrance <br />Is a Building to <br />3e constructed? <br />❑ No <br />Will the OTemporary or Property ❑Platted or Distance from center of highway to front <br />Building be: Xpermenent Is in: ❑Unplafted area ❑Subdivision of building: fee! <br />No, of present >? ° c " Fact location of proposed urea, y t prop�rt , Exact location of present driveway to property <br />driveways to property: ri e <br />Date needed: — <br />Estimated completion date: <br />OPRCE USE ONLY %9 <br />A deposit of $ , payable to Washington County Treasurer, in the form of a Company Check, Certified or Cashier's Check shall accompany the <br />application and will be returned upon final acceptance by the County. No interest shall be earned or paid on this deposit. It is the responsibility of the permit <br />holder to notify the Countv when the work is completed. Check No.__ . -- <br />(1) (We), the undersigned, herewith make application for permission to construct the access at the above location, said access to be constructed to conform <br />with the regulations of Washington County and to any special provisions included in the permit. It is agreed that all work will be done to the satisfaction of <br />Washington County. It is further agreed that no work in connection with this application will be started until the application is approved and the permit issued. It <br />is expressly understood that this permit is conditioned upon replacement or restoration of the highway to its original or to a satisfactory condition. It is further <br />understood that this I it is issued subject to the approval of local city, village, or township authorities having joint supervision aver said street or highway. <br />D' to Signature of Appli� - <br />DO W07 WR07E SEa0W MS AREP <br />ACCESS DRIVEWAY PERMIT AUTHORIZATION — PERpORMANCE REQUIREMENTS <br />Asa condition of this permit, culvert is required: *Nes No Culvert Size max_, Culvert aprons required:' Yes :1 No <br />Storm Sewer present: ❑Yes ❑Flo Locate by date: <br />If the work is not completed by the date given on this application, the cost of completing unfinished construction by County forces may be deducted from the <br />deposit. In the event that coristruction has not started by this date, this permit becomes nWI and void an the permit fee shall be forfeited and the deposit shall <br />be refunded. , GA 7 J �/� . h <br />.S`PFt?i16t PRr]4'lSir'SPdS• . `.. ,. D.#'�"�, .:i'i �< �� �.� � tY �srl i+ , v� <br />Permission is hereby granted for the construction of the driveway as described in this application, said driveway to be constructed in accordance with all <br />regOatons of Washington County and subja t to the above requirements and special provisions. <br />All uvork to be oNpleted by f �� <br />Authorized <br />Copies: ❑Applicant <br />runty Public Works Department <br />I3Coun:y Engineer OMunicipality <br />Revised 9/2013 RPerm1te1Formst kWm Permit.doo <br />