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IIC-II-81 Rev. lY-67 HENNEPIN COUNTY HIGHWAY DEPARTMENT <br />APPLICATION FOR DRIVES Al 0H ENTRANCE 1'F.1011T Permit No. 3671 <br />(For Construction of Private Ihiveway or Entrance from and to a County Road) <br />1 � I L- J7 7 f') I / :� /c mac. t,,� i_ 'E 7_, Vii✓ <br />(Name of Applicant) (Street Address) (City & %ipcode) -(Phone) <br />2. 4_ <br />(Name of Owner) -- _ (Street Address) (City $ "ipcode) (Phone) <br />3. County Road No. Side of Road <br />I N., .., E.. or .) <br />4. Location: miles of _ <br />( N., S., :., or R'.) (TAI.. Co., or Twp. Road) <br />S. Is the property: 9/platted? ❑ Unplatted? <br />4. Purpose of Driveway: VResidence. ❑ Commercial (Specify Type) <br />Yex <br />7. Building to be Constructed: No Date proposed entrance will be needed: <br />8. The driveway will be: ❑ Temporary. Permanent. 9. The Land is: Vligher, ❑ Lower, ❑Level with the Road. <br />1 <br />10. Number of present driveways to property: <br />For Site Layouts see the general-quirements 2 and 3 on the back of this sheet. <br />To help the inspector locate the driveway, place a stake in the center of the proposed driveway, higher than any surrounding brush ur weeds, with <br />a cloth tied to it. <br />I, the undersigned, herewith accept the terms and conditions of the regulations of the Hennepin ..ounty Highway Department and agre o fully <br />comply therewith to the satisfaction of the Hennepin County Highway Department. <br />Dated / <br />ADDlle anl'1 Jrinal Yfe '0" <br />APPLICANT'S DIAGRAM <br />Driveway Layouts shall be 20, 10, or 50 feet per inch. <br />Of Roadway <br />Size, Length and Type <br />of Pipe Delivered: _ <br />Date of <br />Delivery: <br />Inspected by: <br />Driveway was found to be in: <br />ENTRANCE CONSTRUCTION (Do Not Write In This Space) <br />Date: <br />❑ Satisfactory <br />Ej Unsatisfactory Condition. <br />0.5' Min. Depression <br />FILL Sl:( TION, DISTANC LS AND GRADILNIS INDICATED IN RIiD �) i�'� Place Culvcrr If Necessary <br />AUTHORIZATION OF PERMIT <br />In consideration of this agreement to comply in all respvcts with the regulations f heJ oar tment co.efing such <br />operations, permission is hereby 'yf�111r tQriv�eril�ib� Will driveway to he in <br />accordance with the regulations a�' n'�R <br />SPECIAL PROVISIONS: are rLanA wn w <br />It is expressly undersimicl that 1r,. ul-n replaa cmem ur rr..turation of the Bounty Ilighway to its original or to a <br />satisfactory condition. <br />Design Engineer <br />(Complete this f•+rm in quadruplicate and send all copies to: <br />Hennepin County highway Department, Maintenance Office, - - Traffic Superintendent <br />320 Washington Avenue South, Ilopkins, Minnesota 55343. — -- - �— <br />Phone: 935.3381. After apprvcal, one copy will be returned -. <br />to applicant.) ---- <br />,Mainibnance Superintendent <br />IIFNNI.PIN COIINTI IIIGIISAY DEPARTMENT <br />