2. Permit Number:______________
3. Date:*
   Date:
5. Applicant:*
7. Description of Work:*
9. Location of Work:*
11. Note: If requested by the Ford County Administrative Services Department, the applicant shall furnish detailed plans of the work, which shall show the work location, construction details, and the materials to be used.
13. This permit will be subject to the following terms and conditions:
    1. All Work shall be done in strict accordance with the plans approved by the Administrative Services Department. The Administrative Service Department must approve plan changes in advance. 2. Upon completion of all work authorized by this permit, the applicant shall submit to the County “as built” plans accurately depicting the location and the depth of any facilities installed within the County Right-of-Way. 3. As condition to the Issuance of this permit, it is agreed that the applicant shall furnish all labor, equipment, and materials required to do the work solely at its cost; that the applicant has and will maintain sufficient insurance, as required by Federal and State Laws, to protect the general public and Ford County in the event of damage to others as a result of the under-taking of this work; and that the applicant will hold Ford County harmless against any and all claims arising because of this work. 4. All public right-of-way will be restored to a condition equal or better than that, which existed prior to construction. Care will be taken not to destroy monuments. 5. The work authorized by this permit must be completed within 90 days of issuance of this permit; otherwise, the permit becomes null and void, unless the Administrative Services Department grants an extension of time in writing. 6. In the event that the construction plans call for the open cutting of any county roadways, all surface repairs will be made in accordance with the procedures specified by the Administrative Services Department. 7. Construction signing will be installed at the applicants’ expense in accordance with the Manual on Uniform Traffic Control Devices. The applicant will be responsible for the adequate maintenance of these signs. 8. All pipelines shall be a minimum of 30 inches deep or 5 feet below the shoulder line of the adjacent roadway whichever is deeper. Depending on the future construction plans, a greater depth may be required. 9. All excavation within the right-of-way but not within 10ft of the roadway surface will be backfilled and compacted to the density of the surrounding ground. All excavations within the roadway itself or 10ft thereof will be compacted to 95% maximum density. 10. After construction should surface subsidence be detected, the applicant shall repair same within 5 days of notification from the Administrative Services Department. 11. Unless Special permission is granted by the Administrative Services Department, all pipelines crossing roadway surfaces will be installed by boring. Permission will not be granted to open-cut roadways unless absolutely necessary and unless the applicant provides a suitably signed and constructed detour route. 12. No road will be closed, for any purpose, without permission of the County Administrator. Such a request must be made in writing at least 48 hours prior to the closing. 13. The issuance of this permit does not, in any way, give the applicant absolute authority to place the requested facility at its proposed location or depth. In the event that Ford County deems it necessary or proper to make alteration or improvement along or upon the highway or right-of-way, the applicant hereby agrees to make the necessary adjustments to these facilities permitted and hold Ford County harmless for any damage to said applicants facilities, provided however that Ford County provides adequate advance notice of any such improvements. 14. All work now or in the future shall be done in accordance with the requirements of the Administrative Services Department. 15. The applicant shall notify the Administrative Services Department at least 48hours prior to construction. The applicant shall also notify the Administrative Services Department sufficiently in advance so that the facilities can be inspected once they are installed but prior to backfilling. A notice of completions shall be sent to the Administrative Services Department. 16. All facilities installed under this permit shall be protected or monumented in accordance with applicable Federal or State Laws. 17. Any violations of the above terms and conditions shall immediately cause this permit to become null and void.
15. Other Specific Conditions:
17. Please provide a drawing or map of the excavation being done.*
21. Applicant:*
22. Company: *
24. Address*
26. City*
27. State*
28. Zip Code*
30. Phone Number*
31. Email*
33. Submitted by:*
34. Title:*
38. Grantor
    This permit is approved and its provision agreed to by-
40. Signature

    _______________________________

41. Signature

    ______________________________

43. Date:

    ____________________

44. Date:

    ________________________

46. Jonathan Gilbert
    County Administrator
47. Tanda L. Bartlett

    Assistant County Administrator

49. 100 Gunsmoke Dodge City, KS 67801
50. Phone: (620)227-4670 Fax :( 620)227-4717
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field