HomeMy Public PortalAbout1986-029Member •52-/A
;tnd moved its adoption:
introduced the following Resolution
CITY OF MEDINA
RESOLUTION NC). fe �
PERMIT/ RESOLUTION FOR PUBLIC UTILITY INSTAL.I.A.TION
IN CITY H.[Givr OIL WAY
,yy,
WHEREAS lone ,� , a public.
utility licensed to do business ithe Cit of Medina, has made application
to the City for the installation of �/�.ye_e__�' G�J6�_e;
located at �� Of' . e_.,_„,k ,94, -
witllin the City of Nle(ho:l;
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It,1lo virlg conditions:
1. Slret•t and Might of \A ay shall he r e..itorctl it) their
t,l I eonditioi, ltllt,ll colnl,tetition of Irr.;1:111ution
:,ncl Applic:,Itt sh;111 I„' I H1,10 for settlernetil or other
(homage czoisell I)y s;l i11 ins1;111ation roc a perioil ul'
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CITY OF
Permit No.
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.
1. Nature of Work
Installation of gas service main
Type of Surface to be Disturbed
(Check type) (Gravel) (Bituminous) (Concrete) (Boulevard)
2. Location
Street, Avenue and House number
(Additional information attached when necessary)
3. Size and kind of pipe, conduit or cable
Depth from Surface 2.5 feet ±
Dimensions of Excavation
4. Method of Installation or Construction (including method of compaction and excavation)
In accordance with procedures as described in Minnegasco Distribution Department Operations Manual,
Section 500, "Excavating, Backfilling and Surfacing", the most recent edition on file with the permitting authority.
Machine Excavation: Yes X No
5. Work to start within days and completed with
6. Will detouring of traffic be necessary? No If so, describe routing:
days thereafter.
For MINNEGASCO, INC.
(Applicant)
Signed By
Dated
The 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 $ 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