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WASHINGTON COUNTY PUBLIC WORKS DEPARTMENT € Permit No.aOEIT U^I <br />5 a Gogh 11660 Myeron Road North ' <br />County Stillwater, Minnesota 55082 County Road A lb <br />Phone: (651) 430-4313 • Fax: (651) 430-4365 Storm Sewer <br />Ilifty, Service $25 <br />dlily Distribution $100 <br />I Others $100 Permit Fee,^ - <br />APPLICATION FOR RIGHT OF WAY PERMIT = ........................ _........ ........................... ........ __._........ <br />LL APPLICANTS MUST BE REGISTERED WITH WASHINGTON COUNTY TO OBTAIN PERMIT <br />1lameofApplicant Contact Address AA / <br />r- r.Sa- T'O� `TrOF?faS Ido S A L,-���:rtr7o� SJ i � 8co Phone I2_3*- 7r3t/ <br />city ,Z +_e�po 111 r Fax Co12 `18 (7te <br />.ontractor: / '•C W�'�' State/Zip <br />tate and Location ak <br />Toposed Start Date: � Z y -&I (7 Proposed End Date: Sem <br />:ounty Road Number: te.r_ e`er_ City/Township: <br />and Project Limits. Include a Drawing and/or Map if Necessary. <br />Type of Work (Check all that Apply) <br />Install New Underground Utilities _ Install Sign or Monument Grading/Excavation/Boring <br />_ Install New Overhead Utilities <br />_ Install Street/Sidewalk/Driveway/Culvert <br />—Tree/Brush Removal <br />_ Install New Ground -Level Utilities <br />_ Place Temporary Structure or Container <br />Host a Parade/Race/Event <br />Maintenance (No New Installation) <br />_ Install Landscaping <br />—Other (Describe Below) <br />Traffic Impacts (Check ONE) <br />No Traffic Impacts <br />_ Sidewalk, Shoulder, or Trail Closure (Vehicle lanes not affected) <br />_ Closure of Traffic Lane(s) without detour. (Flagging or lane reduction, no re-routing of traffic). A Traffic Control Wan may be required. <br />T Closure of Traffic Lane(s) requiring detour (Traffic being re-routed). A traffic control plan MUST be submitted with permit application. <br />Utility Information I <br />Utility Type: <br />_ Electrical <br />Telephone <br />Cable TV <br />_ Fiber Optic <br />_ Natural Gas <br />Water or Sewer <br />Other <br />For Underground Utilities: <br />Size: <br />Conduit Type: <br />Casing Type: _ <br />Depth: <br />Voltage: _ <br />Pressure: <br />For Overhead Utilities: <br />Installing New Poles? Yes _No <br />Minimum Height of Conductor from ground: <br />Minimum Height of Conductor over roadway: <br />Line Voltage: <br />I/. The applicant shall perform all work accoromg to the terms of this perm t, the Washington County Right of Way Ordinance and all other regulators of Washington County, and any <br />Standard and/or Special Provisions which are attached to the permit The applicant shall comply with all applicable codes, laws, and ordinances including County Ordinance #188. The <br />York performed shall be in no way detrimental to the highway or to the safety of the public. All traffic control shall comply with the provisions of the Minnesota Manual on Uniform <br />rraffic Control Devices, including the Temporary Traffic Control Zone Layouts Field Manual. Applicant shall supply accurate electronic "as -built" drawing files in either DWG or <br />DXF format Files will be accepted in other formats and converted, at the applicanfs expense, to a compatible format If the County cannot convert files, the applicant most convert them <br />o a compatible format Conversion costa will be billed by the County at applicable billable labor rates plus material costs. <br />3ienalurn, ✓ .c�+ —SGJP.-s.nafa L 1)0v 1 2P 1 <br />