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Culvert Permit

2. 

4. Culvert Permit

5. Permit fee: $5.00

7. Date:

9. Applicant information:

11. Name

12. Email Address

14. Address

16. City

17. State

18. Zip Code

20. Phone Number

22. Culvert Location and Description of Work:

24. 

26. Specifications:

28. Pipe Material:

29. Depth of cover (inches):

31. Pipe Size (dia) inches:

32. Bedding Material:

34. Pipe length (feet):

35. F.E.S. Material

37. Pipe Slope: inches/foot

38. F.E.S. Size (dia) inches:

40. I hereby agree to install this culvert in such a manner that it will not inhibit the free flow of water or violate the Soil Erosion Regulations (chapter 157). Should installation of this culvert inhibit the free flow of water or violate the Soil Erosion Regulations, I will be fully responsible for correcting any deficiencies or violations.

42. ______________________________________
    Applicant's Signature

    Applicant's Signature

44. _____________________________________
    Approved by: Edward S. Dolezal P.E. Director of Public Works

    Approved by: Edward S. Dolezal P.E. Director of Public Works

46. This form must be printed, signed and turned into the Village Hall

Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

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