Page 1 of 2 Continued on back Updated 7/25/2019
ADC Map _________
Grid ______________
DelDOT Permit Application
Property Owner's Name: Date:
Mailing Address:
,
Zip Code
Cell No.:
E-mail Address:
Telephone No.:
Fax No.:
Tax Map/ Parcel I.D.
:
(NCC Ex: 0000000000
; KC Ex: 0-00-000.00-00-00.00; SC Ex: 000-0.000-0.00)
Applicant Name: Point of Contact (Name):
Mailing Address:
,
State
Zip Code
Cell
No.:
Telephone No.:
Fax No.:
E-mail Address:
Proposed/Existing entrance/project location (
Mailing Address, Road Name, or Road Number):
Nearest intersecting road (Name):
Distance from entrance/project to nearest intersecting road:
Subdivision Name (if applicable):
Lot Number(s):
Existing and proposed entrance location shall be physically staked in field with property owner’s name, as
a condition of this application. Date when stakes will be placed at entrance:
If stakes are not in place, a permit will NOT
be issued. mm/dd/yyyy
Are you requesting a permit for an existing entrance or a proposed entrance? Existing or Proposed
(Check one)
If applying for a permit for
existing entrance:
* Will you be modifying or relocating the existing entrance? Yes No
If yes (explain):
* Was the existing entrance constructed within the past three years? Yes No
Proposed site/right-of-way modifications (check all that apply): Single Family Dwelling ;
Mobile Home ; ECHO Unit ; Building Addition ; Outbuilding Construction ;
Chicken House ; Farm Entrance ; Additional Entrance ; Entrance Widening ;
Entrance Relocation ; Other (Please describe) ; Roadside Stand (From): (To):
City
State
City
