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2. 
6. Jefferson Township Department of Public Works Only
8. Date Application Received:
   Date Application Received:
9. Date Permit Issued:
   Date Permit Issued:
10. Issue Number
14. Application
16. Name
17. Email Address
19. Address
21. City
22. State
23. Zip Code
25. Phone Number
26. Length of Time for Which Permit Is Desired
28. Block Number
29. Lot Number
33. Road Opening Information
35. What is the name of road to be opened?
37. What is the specific location on road or roads where opening is to be made?
39. What is the size of road opening?
41. What is the purpose of the road opening?
45. Construction Specifications
47. The construction specifications are as follows:
    

    • Ditch to be compacted with quarry processed stone entire depth in 1-foot lifts
      
    • Roadway to be black-topped when finished with 4 inches of FABC to level of road
51. Items Required for Road Opening Permit
53. Please include the following items with this form:
    

    • Application Fee in the amount of $100
      
    • Cash Bond in the amount of $500 (unless otherwise specified by Engineer)
      
    • Scaled Drawing of proposed construction activities.
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55. 1. Receive an email copy of this form.
56. Email address

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57. Submit

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