Permit Application

Please fill out this form as completely as possible for us to best review your application.

Your Information [Required]

Your Name

Address

Address (Continued)

City

State

Zip Code

Your Phone

Location of Work [Required]

Name of Road

Address

Township

Distance from nearest
intersection

Details of the Work

Overhead YesNo

Underground YesNo

Along Road L.F.

Crossing Road YesNo

Is a Utility Involved? GasElectricWaterSewerOther

Is This an
Emergency Repair? YesNo

Will There Be
Excavation Within
3 Feet of or Under
the Pavement? YesNo

Description of work
If excavation is to occur, what is the nature of the work and will it require the cutting of the road or boring there under?

Characters Left:

Who Will Be Doing The Work? [If It Is Not You]

Name

Address

Phone

Disclaimer

It must be understood that this application does not constitute permission to do work within the right of way, but is only an application for a permit. You will receive notices as to our decision to issue a permit for the job.

Submit Cancel