I, _______________________________, do hereby request permission and authority to construct a culvert/driveway on the right-of-way of the Village in accordance with the information provided on this application and the accompanying sketch. (Applicant must prepare a sketch showing location, length and pertinent details.)
ADDRESS: _________________________________________________
Pipe material will be: _________________________________________________
Wall thickness or gauge will be: _________________________________________________
Type of joint will be: _________________________________________________
DATED: ________________________________ , 20___. SIGNED: _______________________
(APPLICANT)
CULVERT/DRIVEWAY PERMIT
APPLICATION Approved ( ) Disapproved ( )
If disapproved, state reasons: ______________________________________________________
___________________________________________________________________________________ _________________________________________________________________________
DATED: _____________________, 20_____. SIGNED: _________________________
CERTIFICATION
The undersigned has inspected the construction and installation set forth above and finds that the same (is) (is not) in accordance with the permit.
DATED: ______________________, 20_____. SIGNED: _________________________