Montezuma County - Utility Permit in County ROW
Entered into DB?
1680 N Dolores R Cortez CO 81321
Phone: (970) 565-8666 Fax: (970) 565-8252 Email: [email protected]
Applicant Name:
Applicant Mailing Address:
Applicant Email:
Phone Number:
Contractor Name:
Fax Number:
Contractor Phone Number:
Contact a Montezuma County Road Dept Foreman at least 24 hrs before commencing work on this project.
If you are unsure which foreman to contact we will notify you
Cortez - Rick Lard
Cell: 749-9228
Dolores - Jim Sattley
Cell: 749-9226
Mancos - Jason Burton
Cell: 560-2484
Round-Up - Brett Likes
Cell: 749-1041
Location of Activity! (Provide an Address or Location Descrition):
Nature of Work
Electric
Telephone
Irrigation Line
Gas
Restoration Planned
Cable TV
Repaving
Fiber Optics
Water Line
Motorized Tamper
New Line
Replacement
Repair
Abandon Line
Reseeding
CONSTRUCTION ACTIVITY DESCRIPTION (Describe the activity and how it is the least impact method of construction. Also
note which side of the road the acivity will take place and the distance from Road centerline it will occur):
and to be completed on or before:(max 45days)
Work to start on or after
Aerial Construction
Open Wire
H-Frame
Cable
Single Pole H-Fram
Vertical
Steel Tower
Cross-Arm
Other___________
Vertical Cross-Arm
Road Surface Type:
High Impact (Road To Ditch):
Cable Plowing/Trenching (Linear Ft)
High Impact Disturbed Area (SqFt)
Applications are Subject to a $50 minimum fee
Underground Casing
Multiple Tile
Transite
Single Pole
Minimum Height Of Aerial Conductor (ft):
*
*
*
*
*
*
Underground Conduit
Aerial Pole Support
OR
Steel Pipe
Clay Tile
Sectional Concrete
Steel Pipe
Poly PVC Sleeve
Other __________
Sectional Concrete
Other___________
Depth (inches):
Casing Size(in):
Method of Underground Installation
Trench
Plow
Backhoe
Boring
Jacking
Pneuma Gopher
Low Impact (Ditch to ROW edge)
Low Impact Miles:
Low Impact Linear Feet:
Cutting
# of Road Bores
# of Road Cuts
Low Impact (per location):
All applicants are encouraged to do construction as far from the road shoulder as possible
Cable Plowing of Gravel Roads along or through a traveled section BY FOREMAN APPROVAL ONLY
All applicants are responsible for the clean-up of the county right of way
No company or person shall dig in, or disturb the county right of way without complying with all the above
In an Emergency situation these regulations shall be complied with and this form submitted the next working day.
Permit Holders must contact property owners where ROW is not fenced
COMPLIANCE WITH LAW: Applicant shall at all time comply with all rules and regulations of the State of Colorado and
Montezuma County including Land Use Regulations in connection with construction, installation, placing or use authorized
hereunder.
PRIOR TO DIGGING APPLICANT MUST CONTACT THE UNCC COLORADO UTILITY LOCATE AT 811 or 800-922-1987
Please enter your UNCC One Call Ticket Number:
The Montezuma County Road Foreman, by authority of Resolution 11-95, hereby authorize the named applicant to do the above:
Utility/Construction Inspection Approved:
Signature, Montezuma County Road Department
Date:
Montezuma County - Utility Permit in County ROW
109 W Main St, Room 305, Cortez CO 81321
Phone: (970) 565-2801 Fax: (970) 565-3420
Construction Activity Sketch:
Permit Date: