Application for Utilies1
Permit No
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X)E 86 Job #M -544
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 Installatwn ofgasnain
Type of Surface to be Disturbed
(Check type) (Gravel) (Bituminous) (Concrete) (Boulevard)
2 Location See attached drawing
Street, Avenue and House number
(Additional information attached when necessary)
3 Size and kind of pipe, conduit or cable 2" AA
Depth from Surface 2 5 feet
Dimensions of Excavation 18" x 100'
4 Method of Installation or Construction (including method of compaction and excavation)
In accordance with procedures as described in Mtnnegasco Dtstrtbutwn Department Operations Manual,
Section 500, "Excavating, Backfilling and Surfacing", the most recent edition on file with the permuting authority
Machine Excavation Yes X No
5 Work to start within 11 3I R3 days and completed with open
6 Will detouring of traffic be necessary? No If so, describe routing
days thereafter
For MINNEGASCO, INC
(Applicant)
Signed By
Dated 11-16-83
Th 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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Proposed
MINNEGASCO MAIN JOBS -S4k
Acct. No 11(.)." 1t
RELEASE FOR CONSTR.
Date
By
COMPLETED
Date
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2" pc (At1/4 tX. S 2 vv\..a.:
Main will lie 3 Ft. 6" below existing street grade
Pipe Req'd.
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Total Pipe \oo' Est. Cost
Foreign Structures Permits Required
Water Co Rd
San. Sew sit s St Hwy.
Storm Sew. R R
Telephone CALL: c_\ e�� c o
Electric N k.�
By D.
Designed `W,
Design Approved JJJ /G
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