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r <br /> G <br /> l P30" o Gas aiu ` <br /> S9 � Pc� rr� �► Field Davin Form Permit Number: <br /> fel. I j �,- <br /> / Permit Expiration Date: g <br /> ®ate: IF <br /> Street Address: �✓Ll ' <br /> Foreman Name: � �1� r(7� CrosnountyL" <br /> . <br /> PM Number: 1 I LI 17Z0 Clty/ -1 <br /> U r`✓� <br /> Concrete W x L Depth <br /> Roadwa —inches <br /> ewalk M 'inches Color:Y/ j Aggregate:Y/ I Decorative/Stamped:Y/ <br /> ewalk —inches Color:Y N j Aggregate:Y N j DecorativelStamped:Y N <br /> Driveway — _inches Color:Y Aggregafe:Y Decorative/Stamped:Y <br /> Driveway —inches Color:Y/ Aggregate:Y Decorative/Stamped:Y <br /> Curb Ramp I Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Size:�41 t/5 <br /> Asphait W x L Depth AdjusUReplace <br /> (ZAsphalt > •3► 1 $inches Manhole Frame . <br /> ea <br /> —inches Sidevialk Gas Valve Box <br /> Asphalt/Concrete Combo ea <br /> _' over_" Secondary Electrical Box ea 13"x 24"j 1T'x 30"j 24"x 36" <br /> Grind —inches <br /> — _ Valve Frame _ __ ea 15" 23" <br /> Asphalt Fabric Valve Cover --- — <br /> Asphalt Berm/Curb I f ea 30"x 30" 32"x 32". 48"x 48" <br /> Saw Cut Depth Other <br /> 1! WxL <br /> If `6.. inches Place Paver/Stone/Brick In Concrete:Y/N <br /> Concret �If -6�inches Traffic Marker Dots <br /> Seat/ ea Reflective:Y/N <br /> W x L Plug 1%"Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width <br /> Noyes <br /> Paint <br /> Thermoplastic If —inches <br /> if —inches ? <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4" 8"112"Crosswalk <br /> (] 41q <br />