HomeMy WebLinkAbout1981-026 Permit - Sewer Connection
$tate of Oregon APPLlCA TION AND PERMIT TO
- OCCUpy OR PERFORM 22454
)EPARTMENT OF TRANSPORTATION OPERA TIONS UPON A Permit Nu~ber:
Highway Division S1 A 1E ti.GHWA Y
Name and Address of Applicant: Applicant hereby applies to the State Highway Division for permission to perform
I I the following ;operations upon the right of way of the all State
City of Ashland Hi~hways excepting Freeways k
City Hall Hig way, No." Jac son county, ~alr
Ashland, OR 97520 within the City of Ashland service area . as shown on the
I , ana
L ~ map or plan ~ttached hereto and by this reference made a part hereof.
D Construct, operate and maintain a pole line.
. Highway Ref. Map No.
D Construct, operate and maintain a i buried cable. D Erect and maintain a non-commercial sign.
IK] service connection pipe line. D Miscellaneous operations and/or
Construct, operate and maintain a sewer facilities as described.
POLE LINE, BURIED CABLE OR PIPE LINE TO BE C(J)NSTRUCTED ALONG OR ACROSS SAID mGHWAY AT:
Mile Mile ENGINEERS Side of Hwy. or DISTANCE FROM BURIED CABLE OR PIPE Span
Point to Point Station to Station Angle of XING. Centerline R/W Line Depth Size and Kind Length
Th s permit is intendld to cover future sew r service ( onnections installed
on State Highway I ight of w y within tl e Service J rea of the City of As hland.
Excepted from this permit a e rights 0 way withi access cor trol lines of the mai
travelle way and on-off raIl ps of Statl Highways esignated a s Freeways.
SIGN TO BE ERECTED ON SAID HIGHWAY AT:
Engineers Distance from Distance fro~ Side of
Mile Point Station Highway Centerline Shoulder ' Highway Remarks
DESCRIPTION AND LOCATION OF MISCEiLLANEOUS OPERATIONS AND/OR FACILITIES
Works
By:
This permit is issued by the Department subject to the term$ and provisions contained
is accepted and approved by applicant subject to said terms aJitd provisions.
Recommended for approval:
By:
Date of Application:
4- Zt.!-Bf
Effective Date:
Fonn ~7 (Rev. 3-78)
SP-70817-'134
EXHIBIT A
_' r
Highway District Engineer
2692 N. Pacific Highway
Medford, OR 97501
Gentlemen:
Under terms and conditions in $lanket Permit No. , the City of
Ashland hereby applies for permission to install a service connection or service
connections in accordance with the following conditions:
Sewer Service
Water Service
Pipe Size and Kind:
Highway:
Mile Post:
Station:
Service Address:
/ / Pipe shall be driven or bored under the surfaced portion of the
highway.
/ / Pipe shall not cross the surfaced portion of the highway.
/ / Open cutting of surface is required.
The work area shall be protected by traffic control devices conforming to and
placed in accordance with the latest, provisions of the Manual on Uniform Traffic
Control Devices for Streets and Highways, U.S. Department of Transportation,
Federal Highway Administration.
Approved:
City of Ashland
By
Highway District Engineer
, 19
Date
, 19
Date
NOTE: When available attachment of a sketch map showing installation details is
desirable.