DELAWARE COUNTY ENGINEERING DEPARTMENT

7700 EAST JACKSON STREET

MUNCIE, INDIANA 47302

TEL: 765-747-7765

DEL CO PERMIT #

DATE

RECIEPT #

CASH

CHECK #

RIGHT-OF-WAY USE PERMIT APPLICATION

APPLICANT

NAME

PHONE#

MAILING ADDRESS

ON SITE SUPVR

ON SITE CELL#

CONTACT PERSON

LOCATION OF RIGHT OF WAY ACTIVITY

TOWNSHIP

LOCATION/ADDRESS

OTHER DESCRIPTION

DATE ACTIVITY WILL START

DATE ACTIVITY WILL BE COMPLETED

DRIVEWAY & MAILBOX

DRIVEWAY CONSTRUCTION

CHECK ONE: RESIDENTIAL COMMERCIAL

LIST DRIVEWAY MATERIAL:

MAILBOX CONSTRUCTION

MAILBOX STYLE: BREAKAWAY(POST) NON-BREAKAWAY(MASONRY)

ALL DRIVEWAYS ARE REQUIRED TO HAVE A 30” (INCH) HARD SURFACE APPROACH OFF OF THE COUNTY ROADWAY

WITH AN 8” (INCH) THICKNESS PLEASE INITIAL

RIGHT-OF-WAY

WILL THE ROAD BE AFFECTED? YES NO

EXCAVATION: EARTHEN SPECIAL BACKFILL(ROADWAY) BORE

OCCUPATION: TRAFFIC CONTROL DUMPSTER PLACEMENT OVER SIZE/WEIGHT LOAD OTHER

DESCRIPTION OF ACTIVITIES:

ALL ROAD CUTS MUST BE BACKFILLED WITH 8” OF CONCRETE AT A MINIMUM

APPLICANTS RESPONSIBLE FOR TOTAL RESTORATION OF THE DIG SITE

PLEASE INITIAL

ACKNOWLEDGEMENT OF APPLICATION

PRINT NAME:

SIGNATURE OF APPLICANT/CONTRACTOR:

DATE: