2. Date
   Date
3. Application is Hereby Made by
4. Address
6. City
7. State
8. Zip Code
10. Emergency 24 Hour Phone
11. Maximum Width of Trench
    Feet Wide
12. Maximum Length of Trench
    Feet Long
14. Depth of Trench
    In Feet
15. County Road Name
16. County Road Number
18. Municipality
19. Block
20. Lot
22. Purpose of Laying
23. Size Pipe
    (Conduit, etc.)
25. Property of/Project Title
26. To Commence
    (Within 30 Days) Regulation #3 - Read Booklet "Time Limitations" Show Location on Sketch, Name Roads, Distance, etc.
28. Call 732-929-2124 (24 Hours Prior to Opening Road)
    
    The Applicant Shall Provide the 1-Call Damage Prevention System Confirmation Number Prior to Excavation
30. 
32. (Curb Line or Edge of Pavement) Road Shoulders / Right of Way are Part of Road
    Describe any Special Conditions
34. Final Surface Restoration Shall be as Follows:
    1. Mill across trench and extend 1' minimum beyond edges of trench to a depth of 1" minimum.
    2. Apply tack coat at a rate of 0.08 gallons per square yard.
    3. Place FA-BC surface course 1" thick minimum using paver at a minimum width of 8'.
36. Permit Fee Paid
37. Amount and Type of Bond Fee Received

    1. Cash
    2. Surety
39. Cash Amount
40. Surety Amount
42. The applicant agrees to accept the conditions of continuing County policy with regard to adjustment of utility structures. The applicant must agree that in the event of modification of the County road, utility adjustments necessary to meet the modification will be at the utility's cost and expense, and in addition, certifies receipt of the pamphlet entitled "Rules & Regulations for Openings," and understands their obligation for Road Openings.
    Signed
44. Date
    Date
45. Permit Number
46. Municipality
48. County Road Number and Name
49. Name of Applicant
51. You are hereby granted permission to make opening in County Road and perform work and install facilities therein in accordance with and subject to the conditions of you application, dated
    You are hereby granted permission to make opening in County Road and perform work and install facilities therein in accordance with and subject to the conditions of you application, dated
53. ...and in accordance with the plan and regulations attached, for service connection to property of
54. ...or construction or extension of
    Main or Conduits
56. Detailed statement of any special conditions or features: Lane/Shoulder Closings shall be between 9 a.m. - 4 p.m. Hot Mix Asphalt must be available on day of road opening.
58. Supervising Engineer
Leave This Blank:


60. Submit Submit and Print

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