HomeMy WebLinkAbout1981-027 Permit - Water Connection
~te of Oregon APPLlCA TION AND PERMIT TO
~ OCCUpy OR PERFORM 22455
[)EPAlnMENT OF TRANSPORTATION OPERA TldN5 UPON A Permit Number:
Highway Division
5T A TE HIGHWAY
Name and Address of Applicant: Applicant hef1eby 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 Highways excepting freeways J k county, ~lt1r
City Hall Highway, No.:, ac son
within the City of Ashland service area
Ashland, OR 97520 , . 8IDl1 . as shown on the
L ~ map or plan 'attached hereto and by this reference made a part hereof.
0 Construct, operate and maintain a pole line.
Highway Ref. MaD No.
D Construct, operate and maintain a I buried cable. D Erect and maintain a non-commercial sign.
[X] a water service conn~c t ionspipe line. 0 Miscellaneous operations and/or
Construct, operate and maintain facilities as described.
POLE LINE, BURIED CABLE OR PIPE LINE TO BE CONSTRUCTED ALONG OR ACROSS SAID HIGHWAY 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
T cds permi is inten ed to cove future wa er service connectioIS installed
on Sta e Highwa' right of way within the servic :> area of t e City of Ashland.
Except ed from tl is permit are rights of way wit !tin access ( ontrol IiI es of the
main t avelled " ay and on off ramps f State Hi ghways desi~ nated as F reeways.
SIGN TO BE ERECTED ON SAID IDGHWAY AT:
Engineers Distance from Distance from Side of
Mile Point Station Highway Centerline Shoulder Highway Remarks
DESCRIPTION AND LOCATION OF MISCiLLANEOUS OPERATIONS AND/OR FACILITIES
This permit is issued by the Department subject to the ter~ and provisions
is accepted and approved by applicant subject to said terms ahd provisions.
(
Recommended for approval:
permit
Applicant: City of Ashland
By J~L'/4< 1 c?~
Allen A. Alsing Director of ic Works
Date of Application: 4 - '2 '{ - B I
By:
DEPARTMENT OF TRANSPORTATION
Highway Division /J'?-lif1
TlUTY PERMI'NNGINEEIt
Effective Date:
s-,-~-rr/
Form 7~:M57 (Rev. 3-79)
51'"70887-734
EXHIBIT A
,....... ~'"
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:
Water Service
Sewer Service
Pipe Size and Kind:
Highway:
Mile Post:
Station:
Service Address:
/ / Pipe shall be driven or ~ored 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
Date
, 19
Date
, 19
NOTE: When available attachment of a sketch map showing installation details is
desirable.