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z <br /> . <br /> ~ j.4 a~ LANE COUNTY DEPARTMENT OF PUBLIC WORKS ForOfticeUseOnly <br /> APPLICATION FOR FACILITY PERMIT <br /> DATE: <br /> ' ~ INCOMPt~~ APPL?C•aTtONS WfiL NOT BE ACCEPTED PERMIT # <br /> AIS~Cf ~f~iya~oN/~H'1 r ~r/~E.t'//E QiJ~~c/C /JD~P~S <br /> PRbI~E not me t~t~ ro~ m~plicant <br /> lt%fat mg ress: Vee~t <br /> ddress a I ~ ress: Veer ress <br /> Ey6eyc aR 9~~0~ . <br /> ZSty, <br /> Mate, ice' ty, fate, Zip C e <br /> Daytime Phone Requires- me hone Required) F <br /> tigZ-.s.~o0 <br /> ven ng P~jhor~ne ~ ~ I e ven n9 ne I e <br /> ~~_~~p~/. d/: t/.S <br /> l:-ma Addre a rte' <br /> Road name ~~t/ ~ R~~ _ MAP -TAX LOT : T t ~ ~ ? bsect' <br /> owruh p ~e edton u ion ax of - <br /> Street address (ff addressed) I77~ /Q/ ?~i~ ~D~ Mile Post of Road ff known Nearest Town ~/~S'C~~ <br /> ~ . <br /> Directions to site tr~rt nearest major cross road /~D .S4ClT~ DUJOSS'O ~~,t?1(/~' Dit! /~/J <br /> CNECKA BOX BELOW, fill in ALL APPLICABLE BLANKS and ATTACH required materials. SEE FORM INSTRUCTIONS ON REVERSE <br /> <br /> ? j?RIVEWAY APRON PERMIT: Attach a she plan showing the proposed driveway work. (See reverse side forlnstructions and site plan checklist) <br /> 1. Choose One: [ ]Constructing New Approach [ ]Modifying Existing Approach [ ]Evaluation of Existing Approach <br /> 2. Width of Access at the property line (Request Minimum ; and a width will be provkied for you) <br /> 3. Number of ex(sting driveways , <br /> 4. Apron Surface Request:. [ ]Asphalt [ ]Portland Cement [ ]Gravel (asphalt ar concrete finish required on paved roads) <br /> 5. Describe how driveway is marked (Staking/llagging ofwork area !s required) <br /> 6. Related Land Management Division PA No. (Attach PA Condltrons ofApproval nd Approved She Plan) <br /> ADDITIONAL COMMENTS ` <br /> ? ROAD CONSTRUCTION PERMIT: Engineered plans and sleety may be required (see reverse side for additional i ~~.^L~~~ ,y <br /> ? ROADSIDE LOGGING PERMIT: ~T~ <br /> Logging Co. Phone Matting Address including Zip <br /> DESCRIBE LOGGING ACTIVITY: , <br /> ? SPECIAL EVENT PERMIT: Complete and attach the special events form. Name of Event: Date of Event: <br /> Q <br /> OTHER WORK WITHIN THE RIGHT-OF-WAY: Work in the right-of-way not ooverect abov . Please desaibe the work in detail. Attach a site plan <br /> ~a <br /> and supporting materials. Please stake or flag the area l'D~t/„~ii'//C7' illc~/ ~d~sTiP/~.~ ~-SU¢iN.~ ~/°f'D ~'y~ <br /> i4SSaCi~StTc~ pE,d~.sT.t'r.>ti~.P~rylos o s DEw.~c 9~ s _ <br /> ? U Each project requires a separate permit antl engineered plans, pproximate mile s Utility Wo Order # <br /> Description of Work <br /> Apptwtlon Is hereby made fa a tadlity pemdt for work to be done MAtlrhr a County Road ~tph4of-way. auMect to aA terms, con~tions, apraemerds. slipulatlau. and provisions d the Issued <br />permit, Dursuant to 1fre <br /> Mee and regulatlona regerdrq roads and rgMaotavay, es set Lath N Lane Code 15205.225 and Lane Manual3.120- 4 and 15.505550, and other appAcable rogldatlon, law, a ardinanos. <br />The undersigned <br /> hereby declares, Certifies and aflNma under penally d law that aA inrorrnetion provided an 8da ram and ells , b the d y ge, .and aamplete. <br /> SIGNATURE (Propertyowner/atdhodzed agent, wrllten verMcatton required) Date ~ <br /> RETURN TO: Lane County Public Works Engineering nnit D k, 3040 N. Delta Highway, Eugene, OR 97408 <br /> Tel. 541/682-6902 FAX 541/68 -8500 Hearing Impaired 541/682-3995 <br /> Iy <br /> lens Coe,iY mmplm Mal,aMsrtrd Fede~t lr.a end raa~elbns ral.IbabdYOinYrlbn.IndudY~Y a,s/Ynalremwah Ob~Nitles /wl (AON)d 1960 Rev 11104A74 <br /> i <br /> <br />