PERMIT NO.____________
PERMISSION TO ENCLOSE
Board of County Commissioners
Lucas County, Ohio
Property Address:
Gentlemen:
I hereby make application for permission to enclose
with
Ditch No.
+/- feet of
conduit approximately
type / size
of
feet
Road Name
Direction
approximately
feet
from
Direction
In Section
Nearest Intersection
Range
, Town
,
Township, Lucas County, Ohio.
I hereby agree that said work will be done at my own expense in accordance with the provisions of law and in accordance with the current
Lucas County Construction Standards. The final surface should be constructed so that it is graded to drain and slopes away from the edge of
pavement. The size and grade of the conduit shall be as specified by the Lucas County Engineer. For plastic pipe, I agree to provide a minimum of 12"
of cover. Contact the Lucas County Engineer’s Main Office at (419) 213-2860 three working days in advance for grade stakes.
Contact the Construction Dept. @ (419) 213-2860 two (2) working days in advance of commencing work under
this permit to set up an inspection. You must also contact the Construction Dept. prior to backfilling for a final
inspection.
This permit may at any time be revoked or annulled for non-performance of or noncompliance with any of the said
conditions, restrictions and regulations thereof. This permit shall be in the possession of the person in charge of the work and shall be
shown on request to any employee of the County Engineer.
Field W ork Required
Field W ork Complete
Recommended by
Date
Inspected by
Date
Application Name
Address
City/Vill.
Zip Code
Keith G. Earley-Lucas Co. Engineer
Approval valid for 6 months from above date
County Rd.:
Township Rd.:
Township:
Date
Telephone
-
-
Certificate of Insurance Required
YES
NO
This permit issued by the Lucas County Engineer
under authority granted by the Board of Lucas
County Commissioners and/or the Board of
Townships Trustees.
LCE-1
REV. 10/14