Permit for Underground UtilitiesPermit No.
L VL
VI 62 Job #M -438
APPLICATION FOR PERMIT FOR INSTALLATION OF UTILITIES
OR FOR PLACING UNDERGROUND CONSTRUCTION
Name of Party or Organization performing work MINNEGASCO, INC
Address 201 South Seventh Street Telephone No 343 -7023
1. Nature of Work Installation of gas aAxmcmatn
Type of Surface to be Disturbed
(Check type) (Gravel) (Bituminous) (Concrete) (Boulevard)
2. Location Indicated on attached drawing in red of Job #M -438
Street, Avenue and House number
(Additional information attached when necessary)
3. Size and kind of pipe, conduit or cable 1¼"E, 2" PE
Depth from Surface 2 5 feet
Dimensions of Excavation 18" x 175'
4. Method of Installation or Construction (including method of compaction and excavation)
In accordance with procedures as described in Minnegasco Distribution Department Operations Manual,
Section 500, "Excavating Back filling and Surfacing'; the most recent edition on file with the permitting authority
Machine Excavation: Yes X No
5. Work to start within 10 -18 -83 days and completed with 12 -31 -83 days thereafter.
6. Will detouring of traffic be necessary? No If so, describe routing:
For MINNEGASCO, INC
pplicant)
Signed By r
Dated 10 04 R3
The date when work is completed must be reported to the person designated by municipality.
AUTHORIZATION OF PERMIT
Upon payment of permit fee in the amount of 10.00 and in consideration of the agreement to comply
in all respects with the Street or Alley excavation ordinances and regulations applicable covering such operations,
permission is hereby granted for the work to be done as described in the above application, said work to be done in
accordance with special precautions required, as hereby stated:
It is expressly understood that this permit is conditioned upon replacement or restoration of the road surface to its proper
condition in accordance with the appropriate rules and regulations. It is further understood that this permit is subject
to revocation within ten (10) days of receipt of copy of application by the County Engineer when the permit is for work
on a County Road.
APPROVED
DATE
All requirements shown on reverse side to be complied with.
White copy to applicant, yellow to Municipality Engineer, blue to Municipality Street Superintendent.
Form 16 R3/82
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