Delaware County Engineering Department

7700 East Jackson Street

Muncie, Indiana 47302

Tel: 765-747-7765 Fax: 765-741-9620

Del Co permit #

Date

Receipt #

Cash / Check #

Right-of-Way Use Permit Application

(Make check payable to the Delaware County Engineering Department)

Applicant

Name

Phone #

Mailing address

Utility ID

On site supervisor

Contact person

On site cell #

Location of Right of Way Activity

Township

Address

Or other description

Date activity will start

Date activity will be completed

Driveway & Mailbox

Driveway construction

What is the purpose of driveway? Residential Commercial

What type of material will be used for the driveway?

Mailbox construction

What type of mailbox will be used? Breakaway Non-breakaway

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? 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

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 certify that the information contained on this form is complete and accurate.