P.W. FORM: afe2.22.feb.06 REV 20 JULY 2020
Application for Excavation Within Right-of-Way
(Retu rn to Pu bli c Works/ En g inee ring , Ci ty/Co u n ty B uild ing, 30 0 W A s h S t re e t, R oo m # 2 05)
This permit application is intended to document excavations performed within public right-of-way, and to provide the
permit holder with a checklist of typical requirements.
Name of Permit Holder: _________________________________ Application Date: __________
After hours/emergency phone number:______________________
Address of excavation: __________________________________
Lot No: _______ Block No: _______ Addition: _______
Reason for excavation: ________________________________________________________________
NEW WATER/SEWER - Applied for a water/sewer tap permit with the Utilities Department
Anticipated start date: __________ Anticipated completion date: __________
Surface Type: Concrete Asphalt Gravel Sand Brick Turf Other________________
Size of excavation: ______ Length x _______ Width x _______ Depth
Location of Excavation: Roadway Non-Roadway Alley Unimproved Utility Easement Other
______________________________
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General Requirements:
1. If the excavation is located within a roadway or alley, or requires equipment or materials to occupy a roadway, a traffic control plan
shall be attached to this application. Traffic Control plans shall conform to the requirements of Part 6 of the Manual on Uniform Traffic
Control Devices.
2. 48 hours advanced notice is required for excavations which require a roadway to be totally closed except in the case of an emergency so
that emergency services personnel can be notified in advance.
3. All excavations and related work shall be performed in compliance with OSHA’s PART 1926 -- SAFETY AND HEALTH
REGULATIONS FOR CONSTRUCTION.
4. Excavations in roadways and alleys shall be backfilled and surfaces repaired by the Streets Work Group at the permit holder’s expense.
(For list of fees that may apply see the fee schedule on the reverse side of this application).
5. Permit holder must notify Building Services (785)309-5715 when waterline and sewer line work is ready for inspection. Work permit
must be obtained from building services.
6. When backfill and roadway/alley repairs are required by the Streets Work Group, the permit holder must notify the Streets Work Group
(785)309-5750 after the Building Services inspections are completed.
7. Permit holder’s traffic control shall remain in place until the Streets Work Group is available to assume responsibility of traffic control.
8. Excavations shall be covered or fenced when unattended.
9. If the excavation will occur within 10’ of tree located in the right-of-way the permit holder must notify the City Forester at (785-826-
7275 or email brett.lamer@salina.org.
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yes no (
) Please answer the following questions:
If working within the roadway or alley, has a traffic control plan been designed and attached to this
application?
Do you anticipate total closure of the roadway? (Advanced notification to emergency service is required by
Public Works)
Will installation be within five (5’) feet horizontal or two (2’) feet vertical of public water or sewer lines
and facilities? If “YES”, provide a site plan showing utilities and clearances.
Is there a tree within ten (10’) of the excavation? (Notification to City Forester required by Permit Holder)
By signing this application the permit holder verifies that the information provided is correct and understands that all work performed,
including temporary traffic control, within the public right-of-way remains his responsibility until the Streets Work Group is available to
assume responsibility. This permit does not absolve the permit holder of any local building codes, engineering standards or safety standards.
Approved by:_______________________________________________ Date: ________________
Applicant Signature:_________________________________________ Date: ________________
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