DELAWARE COUNTY ENGINEERING DEPARTMENT
7700 EAST JACKSON STREET
MUNCIE, INDIANA 47302
TEL: 765-747-7765 FAX: 765-741-9620
RIGHT-OF-WAY USE PERMIT APPLICATION
(MAKE CHECK PAYABLE TO THE DELAWARE COUNTY ENGINEERING DEPARTMENT)
Applicant
NAME
PHONE#
MAILING ADDRESS
FAX#
UTILITY ID
CONTACT PERSON
PHONE#
Location of Right of Way Activity
TOWNSHIP
ADDRESS
OR OTHER DESCRIPTION
DATE ACTIVITY WILL START
DATE ACTIVITY WILL BE COMPLETED
Driveway & Mailbox
WHAT TYPE OF MATERIAL WILL BE USED FOR THE DRIVEWAY?
ALL DRIVEWAYS ARE REQUIRED TO HAVE A 30" HARD SURFACE APPROACH OFF OF THE COUNTY ROADWAY
PLEASE INITIAL
Right-Of-Way
WILL THE ROAD BE AFFECTED?
EXCAVATION:
OCCUPATION:
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
APPLICANTS RESPONSIBLE FOR TOTAL RESTORATION OF THE DIG SITE
PLEASE INITIAL
Acknowledgement of Application
PRINT NAME:
SIGNATURE OF APPLICANT/CONTRACTOR:
DATE:
INDEMNIFICATION AGREEMENT:
The petitioner/applicant hereby agrees to hold harmless, defend and to indemnify Delaware County from or against all claims, damages and expenses, including but not limited to reasonable attorney's fees on any property arising, alleges injury and/or death to any person or damage to any property arising, or alleged to have arisen out of any act of commission or omission on part of petitioners/applicant, his/her heirs, successors or assigns regardless of whether such acts are direct result of the public right-of-way use pursuant to this permit grant. I CERITFY THAT THE INFORMATION CONTAINED ON THIS FORM IS COMPLETE AND ACCURATE.