HomeMy WebLinkAbout1977-11-08 Hennepin Co Application for Utility Permit Pg1"C 5136 NENNE►IN COUNTY O O�
N1WWAY DEPARTMENT
320 sosh,natoa Arsnue South
Meplli—s, r.,,.rso.e 5534 lY 277
AMPLiCATHM FOA WASTALLATNM OF UTILffW8
VILLAM Oi 0"d
County Recd Ne. —___— Persia NO.
wnicipali•y
LOCATION AND/011 DESCRIPTION Of WORK Application is hereby made for permission to place, construct and th•reeftw msinbin a
it t. i1 ... I
610041 r across County Hi41bway Ne. (bate. at)
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NAME ref sawita6t -1. ii oCr. Y Phone
Additives 7:,_t iii .t•It `•
CITY $TATE Lip COOL
Party Or, erpni/aeiea 41eSfMatiw41 work
Address yam :1s &Juvtj
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Phone (Business) 01'oy1f
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Phone(Emergency) -
1. AERIAL CONSTRUCTION - Submit detailed print showing type and location of installation.
2. UNDERGROUND CONSTRUCT1014
CONDUIT
INSTALLATION
CASING
r] Multi duce tile
Pip class
Seel pi pe
❑ Transit•
Type bedding
Other typo ____
r] Clay of concrete
Service type _-__
Sia6 —
FI
Steel, test or plastic
Size �_t
Depth _
Otho.
Depth
3. METHOD OF INSTALLING UNDER ROADBEDS (If open trench, explain why necessary)
�] Bering L—
4. AREA TO BE DISTURBED
TRAVELED SURFACE
[] Concrete
`J Bituminous
Other
STRUCTURES
❑ Bridge
❑ Bax culvert
❑ Pipe (Concrete, metal]
SHOULDER
Bituminous
❑ Gravel
Other ___--
D C.rrb i1 Gutter
❑ Sidewalk
Other _
[:) ❑ Open trench
BOULEVARD
] Sed
[ ] Field Gross
Other
[] Trees
0 Shrubs
❑ Plentings
5. The surface will be restored and all wot k under this permit will be completed on or befc, c — —
DATE
(PERMIT IS VOID AFTER THIS DATE)
If work cannot bo completed within dates specified, o written request for permission of extension must be made to the Hennepin
County Highway Department.
Except for the negligent acts of the County, 'is agents and its employees, the Utility or Pemtittes shall assume all liability for and
save the County, its agents and its employees, harmless from any and all claims for damages, actions or causes Of action arising
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,
reconstructing, maintaining and using of said utility under this application and Permit for construction.
(t, Me) the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin End
e;roe to fully comply therewith to the satisfaction of the County Highway Department.
LAS ('011"Okl4y
Organization -
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B y {.e
MAINT. N-ov 1 P 1977 RFC'Q a ..