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<br />1 ~ LANE ~auluTY DEPA~TM~NT aF Pua~~c woaKS ~ Fat<o~~ v~~ o~y .
<br />~ ~ ~ ~ ~ • ~AP~L~~AT~o~N ~aa FAc~L~TY PERMIT DAB: . , } ~ ,
<br />. rN~o~~i~,aPpLfcar~aNS~I~~~ Nar~E~,a~c~Pr~~ r SEE PA E 2 PERMxT # ~ ~ ~ C FAR INSI7twt~~~QN~ ItNl~ FEES
<br />ALL. PLANS ll~tlSr~E ~'t`X~~ OE S~ G~NI„~S IAN F.LEC~"RQN[G ~Q!P'y1S P1~D1l1DEL?
<br />~ C~ Ofi~`tL~ENE ~
<br />~ PLi A T: P nt Name ~ PROPERTY O ER: Print Name ttf different from,Appiicant3 .
<br />99 East Broadwa #400
<br />Mailing Address; Street A dress ~ a~iing dress: Street Address i
<br />Eu ene QR 9T409 ~ Ctty, State, Zip Co e . pity, State, Zip Code
<br />.549 6$2-5249 549 682~5032~
<br />Daytime Phone Required FAX ~ a~yl~'me hone Requit~d~~ ~ ~ . ~ ~ v .
<br />! X549.5. -0 a2 Evening Phone Cell ~Pione ~ ~ ~ vening Phone I Prone •
<br />Kris.d.alson a.eu ene.or.us ~ ~ ~ ~ ~ F-tnaii Address ~ Etna i~ dress
<br />f ~ ~ ~ . f ,
<br />(~3 Raad name Watson Dr ' {3~ MAP ~ TAX LOT . tl Q4 0~ 22 04~gD 4rrr~..~-rrr~rw ~ ~rrrr. w..+.rr+rw~ •..w~m..r~,~~ ~ ~ Townshrp .Range Seaion. Sub'sectian Tax Lot
<br />f ~4~ Street address tiff not addressed put ILIA} N!A Approxirpate~ Mite Past~of; Roads Nearest Town..
<br />i (6},Directjons to site fil~am~nearest major Goss road East oti S ~ tiro Creek road then a roximatel. ~~393' orth tQ W tson.Dr . .
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<br />• ~ ChfECK DNE ROX gEL41N rKA T B~Sr AESC#~IS~S rNF waRK YOU P~.A;d~ r0 PERFOI~~' ANO'A.T~~Cd~ RAE •#ll~Ep' NfA7`Ed~l~tS ~ • ~ •
<br />~ (8) DRIVIw~VAY APRON ~PER1~lT: YnU ~MUS'T CQMPLETE A ~ H BEL4Vi[ IF YOU HAVE CHEGKEb T'HE DRNEVIi'AY APRON ~~D~.
<br />a. ~A#tach a plot pion ~ 1 x~ T or smaller.. ~!f yQ.u one building yr f~ave a' ..arrniri acfion #urn in fdxe same don au wd[~, rov~de f~ Land
<br />f b. Choose Qne: ~ jCor~structing..Ne~r Approach. [ ~Mod'ttying E~asfing. Approach:. ~ Evaluation of fixing. App~ach•
<br />' ~ c. Wid#h.of driveway access a~ahe ProPertY IEne.. (ono choice fs~made, ~we~wr"Clprwrde ydu wff~ fhe mFn~mum re ulremer~f }
<br />. ~ d. ~ Aprvn Surface Requ~st,° . [ lAsphalt • [ ]Concrete ~ ~~ravel ~~sphadf or conc~fe~ ~ndsl?. ~ds n~qudred on~ pawedroads)
<br />e, How many tax Tots ~nli this access serve? Now many accesses currenljy east?
<br />E ~ f. ~ Staking or fla in of the area is r aired. Describ 99 9 eq a how the access is marked.
<br />` g. !s this permit a requirement fog A Buildin Perrnit? Y or N r ~ ' ' ` ~ g . C7 C~ A Planning Acl~ian? Y or N Q (If yes~af#aclr candrfrons of approval) ~
<br />- h. Deseri~e the purpose of the access? hex home, R1(,parldng, indt~trialy ~
<br />i. Add~#tonal~ Comments
<br />PRQJECT DENELaPMENTIRC}AD C~}NSTRUCTION PERMIT: Engineered cans and sure ma be~ uired~ SEE REVERSE P tY Y ~ ~
<br />(i~) ROADSIDE L~~,,~IN,G~P_E,.,,,R~[~T: Staking or flagging at the area Is required. Describe how the loc~tivn is marked
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<br />~ Logging Ca. ~ Phone ~ 1 ~ Mailing Address including Zip
<br />l Describe Logging Activity:
<br />I ~ 4~x) UTILITY P, ~RMIT: Submit ~ ~X~ l or smaller engineered plans. MUST mark locations w~h Pain#~or:fla~ging: Mork Qrder # .
<br />~ ~ APProx mile post Description of Work ~ . •
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<br />~ ~ ~.2~ QTHER WORK WITHIN THE:RICHT=OF-WAY. Was~C in the ti ht-of wa not covered above, Please describe the work in detail. Attach.a.
<br />~ 9 - Y site
<br />.plan and supporting rrlatetials. Please stake ar fag the .area
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<br />~ Apprica~on is hereby made for a ~t~i#y.pertr~t for wtulc'to dbrte within a ~ goad rtght~af~ray, subject to a~. terms, canditivris,.agreemerds, sti~utaGans, and provisions ol'the iss0etl
<br />~rmit, pursuant~M the, . ~ ~ - rues Arid r~utatlons regar~ng rods ar~d righ(s~f-rvay, as set•fOrth` to Lase 15.5-225 acid I,~ie Manuat 8.1~t1-~24 and ~15.505.550, and any other applica~e
<br />aeon, iaw, a adar~nce..'1'he undeisigr~ed
<br />I'I ~ hereby dedai~s, oe~es and ai~rn~ under peaaf~y ct law that al! Inftmrrsa5orc on tt>is.fam. ~ ~ bo the best of my:kno~vledge, true and.. late. • .
<br />• E : iN ~ S ~ ATURE ~r n r . wne /ata#honzed 1, ~ •U . ~ ~~Y age Date
<br />~ ' ( ~ RETURN TO: Lane County Public works Engineering Permit Desk, 3D40 N. Dei~a~Highway, Eugene, ~R 9l4 ~ ~ .
<br />• ~ .Tel, 5491fi82-6902 ~ ~ FAX 5491682-~5DD Hearin Im fired 5411682-3995 . 9 pa
<br />~ Sane Cn~ly bot~piies ~ S#a~s and Federni laws and regciabivns ring b ~ani>~an, I~dl~the Americ~rtswttN~~ Act(Atk4~ of 199Q Re+r ~7A#ib7 t i
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