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"C 5136 NENNE►IN COUNTY O O� <br />N1WWAY DEPARTMENT <br />320 sosh,natoa Arsnue South <br />Meplli—s, r.,,.rso.e 5534 lY 277 <br />AMPLiCATHM FOA WASTALLATNM OF UTILffW8 <br />VILLAM Oi 0"d <br />County Recd Ne. —___— Persia NO. <br />wnicipali•y <br />LOCATION AND/011 DESCRIPTION Of WORK Application is hereby made for permission to place, construct and th•reeftw msinbin a <br />it t. i1 ... I <br />610041 r across County Hi41bway Ne. (bate. at) <br />N <br />NAME ref sawita6t -1. ii oCr. Y Phone <br />Additives 7:,_t iii .t•It `• <br />CITY $TATE Lip COOL <br />Party Or, erpni/aeiea 41eSfMatiw41 work <br />Address yam :1s &Juvtj <br />• T -- <br />Phone (Business) 01'oy1f <br />s r E <br />Phone(Emergency) - <br />1. AERIAL CONSTRUCTION - Submit detailed print showing type and location of installation. <br />2. UNDERGROUND CONSTRUCT1014 <br />CONDUIT <br />INSTALLATION <br />CASING <br />r] Multi duce tile <br />Pip class <br />Seel pi pe <br />❑ Transit• <br />Type bedding <br />Other typo ____ <br />r] Clay of concrete <br />Service type _-__ <br />Sia6 — <br />FI <br />Steel, test or plastic <br />Size �_t <br />Depth _ <br />Otho. <br />Depth <br />3. METHOD OF INSTALLING UNDER ROADBEDS (If open trench, explain why necessary) <br />�] Bering L— <br />4. AREA TO BE DISTURBED <br />TRAVELED SURFACE <br />[] Concrete <br />`J Bituminous <br />Other <br />STRUCTURES <br />❑ Bridge <br />❑ Bax culvert <br />❑ Pipe (Concrete, metal] <br />SHOULDER <br />Bituminous <br />❑ Gravel <br />Other ___-- <br />D C.rrb i1 Gutter <br />❑ Sidewalk <br />Other _ <br />[:) ❑ Open trench <br />BOULEVARD <br />] Sed <br />[ ] Field Gross <br />Other <br />[] Trees <br />0 Shrubs <br />❑ Plentings <br />5. The surface will be restored and all wot k under this permit will be completed on or befc, c — — <br />DATE <br />(PERMIT IS VOID AFTER THIS DATE) <br />If work cannot bo completed within dates specified, o written request for permission of extension must be made to the Hennepin <br />County Highway Department. <br />Except for the negligent acts of the County, 'is agents and its employees, the Utility or Pemtittes shall assume all liability for and <br />save the County, its agents and its employees, harmless from any and all claims for damages, actions or causes Of action arising <br />out of the work to be done h -rein and the cc--tinuing uses by the Permittee, including but not limited to the placing, constructing, <br />reconstructing, maintaining and using of said utility under this application and Permit for construction. <br />(t, Me) the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin End <br />e;roe to fully comply therewith to the satisfaction of the County Highway Department. <br />LAS ('011"Okl4y <br />Organization - <br />11— - <br />B y {.e <br />MAINT. N-ov 1 P 1977 RFC'Q a .. <br />