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� H 5136 HENNEPIN COUNTY �i � � � M <br /> DEPARTMENT OF TRANSPORTATION V a '" � <br /> 320 Washington Avenue South `r � C <br /> Hopkins, Minnesota 55343 �� V � <br /> APPLICATION FOR INSTALLATION OF UTI � <br /> 15 <br /> County Road No. Permit No. <br /> Municipality Orono <br /> LOCATION AND/OR DESCRIPTION OF WORK Application is hereby made for permission to place, construct and thereafter <br /> maintain a <br /> along or across County Highway No. (from,at) a ong proper y i ne <br /> to <br /> NAME of a licant Urban P. Kerber' N Phone 473-3641 <br /> Address ��85 Bay Ri ge Roa , Wayzata , <br /> city state zip code <br /> Party or organization performing work res i dent <br /> Address S dm@ <br /> �ity state zip code <br /> Phone (Business) Phone (Emergency) <br /> Regrade bank due to washout by heavy rain 7/24/87 <br /> 1. TYPE OF CONSTRUCTION —Submit five copies of detailed print showing type and location of installation. <br /> ❑ Underground ❑ Aerial ❑ Other <br /> 2. TYPE OF UNDERGROUND CONDUIT <br /> Size Depth Size Depth <br /> ❑ Multiduct ❑ Iron <br /> ❑ Plastic ❑ Copper <br /> ❑ Concrete ❑ Cable <br /> ❑ Steel � other <br /> 3. METHOD OF INSTALLING UNDER ROADBEDS <br /> ❑ Boring—Jacking—Pneumagopher <br /> ❑ Casing—Required for all conduit exceeding 4 i�ches in diameter <br /> ❑ Open Cut—Explain why necessary <br /> 4. AREA TO BE DISTURBED <br /> TRAVELEDSURFACE SHOULDER BOULEVARD <br /> ❑ Concrete ❑ Bituminous ❑ Sod <br /> ❑ Bituminous ❑ Gravel ❑ Field Grass <br /> STRUCTURES <br /> ❑ Curb&Gutter ❑ Culverts ❑ Trees <br /> ❑ Sidewalk ❑ Road Signs ❑ Shrubs <br /> ❑ Signals ❑ Other <br /> 5. Atl work under this permit will be completed on or before <br /> Date <br /> (PERMIT IS VOID AFTER THIS DATE) <br /> If work cannot be completed within dates specified,a written request for permission of extension must be made to the Hennepin County <br /> Department of Transportation. <br /> Except for the negligent acts of the County, its agents and its employees,the Utility or Permittee shall assume all liability for and save the County, <br /> 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 herein and <br /> the continuing uses by the Permittee, including but not limited to the placing,constructing, reconstructing, maintaining and using of said utility <br /> under this application and Permit for construction. <br /> (1, We) the undersigned, herewith accept the terms and conditions of the regulations as laid down by the County of Hennepin and agree to fully <br /> comply therewith to the satisfaction of the Hennepin County Department of Transportation. <br /> Organization <br /> By Date <br />