Sign the printed copy and deliver it with your $50 check to the Engineer’s office at 1660 Island Road.
Pickaway County Engineer, Highway Department
1660 Island Road, Circleville, OH 43113 · Phone 740-474-3491 · Fax 740-477-1784
Lot split requirement
Permit # (county use)
Permit expires 1 year from preliminary permit approval date
This permit is required to be submitted to and approved by the Pickaway County Engineer prior to any newly created lot being approved in unincorporated Pickaway County along county and township roads.
Property Owner (Applicant/Contact)
Current Address
City, State, Zip
Phone #
Email
Township
Subdivision
Road Name
Lot Number
Located between these addresses
and
Length of Property Frontage (feet)
Additional Information
Proposed Access Use (Single Residential Access, Farm Field Access, Commercial Access, Common Access)
Fee = $50. Make check payable to “Pickaway County Engineer”
Type of Road (Local Road, Minor Collector, Major Collector)
Fee Paid $
Receipt #
Initials
Date
Preliminary Driveway/Access Approval, as described above, by
Form revised 9/26
Nothing on this page is transmitted to the county. Print it, sign it, and deliver it as the form directs.
