2. Ford County Application Date*
   Ford County Application Date
3. Survey Number
5. Name*
6. Company*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Applicant is a licensed land surveyor in the State of Kansas and hereby requests permission to excavate in County and/or Township roads/right of ways to determine the exact location of existing monuments of G.L.O. corners.
16. SCOPE OF WORK*
    Legal Description (s) of Recovery Work:
18. Road Identification:*
19. Number of Monuments in Search:*
21. Estimated Start Date & Time *
    Estimated Start Date & Time

    Estimated Start Date & Time
22. One Call ID:*
24. Date Called In:*
    Date Called In:
25. Date Expired:*
    Date Expired:
27. Conditions:
    1. Applicant shall contact KS-ONE-CALL and provide proof of notification. 2. Applicant shall cooperate with all utility companies affected by the excavation. Some private utilities (water, gas or other lines) may be within the right of way. It is the responsibility of the Applicant to determine the utilities affected and take appropriate measures to ensure there is no damage caused by any property. 3. Applicant shall notify Ford County Surveyor or his designee before the work is initiated and again when work is completed. 4. Applicant shall carry "General Liability" insurance under a claims-made policy that has a minimum combines single limit of $2,000,000.00 for personal injury and property damage. Further, Applicant shall carry "Worker's Compensation and Employer's Liability" insurance that complies with Kansas state law. Applicant shall carry "Automobile Liability" insurance under a claims-made policy that has a minimum combines single limit of $1,000,000.00 for personal injury and property damage. Prior to signing this application , Applicant shall furnish to Ford County Surveyor "Certificates of Insurance" showing the applicant carries insurance in the amounts and types required herein. The "Certificates of Insurance" shal show Ford County as an additional insured and loss payee. 5. Applicant shall be responsible for erecting and maintaining all traffic control devices necessary to protect the traveling public and all workers involved in the excavation. The traffic control devices shall be in compliance with the Manual of Uniform Traffic Control Devices(MUTCD), appropriate for the volume of traffic on the roadway. 6. Ford County may provide equipment and employees to assist in the excavation and backfill of the dig. The cost to Applicant shall be $15.00 per man hour. Employee time shall include moving equipment to the excavation site, excavation, backfill and return to the base location. There shall be a minimum of five (5) working days notice prior to excavation. The Ford County Administrator shall determine in his sole discretion whether Ford County equipment and employees will be provided to assist with the project. There shall be a $50 charge if the request to excavate is not cancelled at least 24 hours prior to the date scheduled for the excavation. 7. In the event Ford County does not provide employees and equipment to assist tint he excavation and backfill of the dig, the excavator used by the Applicant shall be approved in advance by the Ford County Administrator. 8. Applicant shall be responsible for the costs of hard surfacing materials, such as bituminous or concrete materials, required to return the excavation site to its condition prior to excavation. 9. Applicant shall within 60 days of the excavation provide the Ford County Surveyor's Office corner certificates and a digging report for all corners excavated. The corner certificates shall meet state standards and the digging report shall provide sufficient information to accurately locate the dig area. If the applicant does not provide a corner certificate or dig report for each location within 60 days of the excavation, applicant shall be responsible for all equipment, materials and staff time expended for the project at Ford County's current rate plus overhead. 10. Applicant will be denied excavation if location is an established corner located in asphalt that has a monument box.
29. Certificates of Insurance
31. 11. Other Conditions:
33. By signing this application I agree to all the conditions stated herein.
35. Applicant*
37. Approved this______day of______________________, 20___.
39. _________________________
40. _________________________
42. Jonathan Gilbert
    County Administrator
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field