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(Street/Box Number & Name of Street)
At Edge of Road
At Property Line
Within Town Way
(Yes or No)
Show proposed entrance locations, width and arrangement; distance between entrance; setback 9from edge of traveled way) of buildings, gasoline pumps, etc.; location of existing culverts, pipes, catch basins or manholes, curbing, gutter, and sidewalks; and the location of proposed culverts, ditches, curbing and sidewalks.
I am duly authorized to execute this application and have reviewed and will comply with the above. I further agree to comply with all requirements of the Entrance Permit and agree to pay any subsequent charges which may become due as a result of my failure to comply with any of the permit requirements of the Right of Way Ordinance.
This field is not part of the form submission.
* indicates a required field