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Smac . <br /> FaVfio Gas--`""nr avng Form <br /> Permit Number: <br /> Field Pi <br /> Permit Expiration Date: <br /> Date: <br /> Street Address: <br /> Foreman Name: <br /> Cross <br /> PM Number: L ` <br /> Ci /County: <br /> Concrete �V1(V <br /> W x L Depth <br /> Roadway _inches <br /> Sidewalk —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Sidewalk —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb qlf Gutter:Y/N <br /> Valley Gutter If <br /> Dowels Edea Size:#41 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt inches Manhole Frame <br /> ea <br /> Mill&Fill _inches Sidewalk Gas Valve Box <br /> ea <br /> Asphalt/Concrete Combo _'over_" Secondary Electrical Boxea 13"x 24" 17"x 30"124"x 36" <br /> Grind —inches Valve Frame ea 15" 123" <br /> Asphalt Fabric Valve Cover hea 30"x 30" 32"x 32" 48"x 48" <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L <br /> �oncrete <br /> If r�inches Place Paver/Stone/Brick <br /> In Concrete:Y 1 N <br /> If —inches Traffic Marker Dots <br /> ea Reflective:Y/N <br /> Seal W x L Plug 1%"Gas Prospect Hole Nea Concrete Asphalt <br /> Slurry/Fog/Sand LTJ <br /> Striping Width <br /> Notes <br /> Paint If —inches <br /> Thermoplastic If _inches <br /> Traffic Legend <br /> Double Center LaneHl�f <br /> f <br /> 3M"Scotch Lane" 4"18"112"Crosswalk <br /> r (/ <br /> v` <br />