Application to Work in County Road Right of Way

Open blank official PDF

Sign the printed copy, then deliver it with your project plans to the address in item 7.

Pickaway County Engineer

Sterlin C. Mullins, P.E., P.S.

Application for Permit to Work Along or Across Pickaway County, Ohio Roads

At the following described location

If this permit is granted, I/We agree to the following conditions:

  1. The traffic will be maintained at all times, unless written permission is granted by the Pickaway County Engineer to close the road.
  2. Pickaway County Engineer Department must be notified 48 hours prior to start of work.
  3. A right of way request is required, and a verified right of way must be shown on the submitted plans.
  4. Any shared pole use must submit the shored use agreement.
  5. The disturbance to road surface and shoulders will be kept at a minimum and trenches will be backfilled with gravel and tamped so that settlement of the material will be minimized. If settlement does occur, additional suitable material will be put into place and compacted.
  6. The road surface at the trench will be replaced with material of the type that was removed and the new surface shall conform with the grade of the undisturbed surface.
  7. Lights, signs, barricades and, if necessary, flaggers and watchmen will be placed on the job for the protection of traffic at all times, day and night, during the time this work is being done and instructions given by the Pickaway County Engineer's Department, as to handling of traffic, will be fully complied with.
  8. I/We assure the responsibility for and will save Pickaway County harmless from any and all claims for personal injuries and property damages and shall defend any action that might be brought due to this work. To cover this responsibility, I/we have the following insurance which is now in force and will remain in force during the prosecution of this work:
Insurance in force during this work
Amount For Policy Number Insurance Co.
  1. Responsibility under this permit will remain in force until a release has been granted by the Pickaway County Engineer.
  2. Please provide a copy of complete plans for your intended project with this application to Marcus Cradlebaugh, 1660 Island Rd., Circleville, Ohio 43113. Phone: 740-474-3491 Fax: 740-477-477-1784 or mcradlebaugh@pickawaycountyohio.gov

If approved, permit expires 90 days from permit approval date, unless otherwise noted by Pickaway County Engineer's Department

Applicant

Applicant Signature (sign after printing)

County use only

P.C.E. Signature

Approval Date

PCE Permit #

Nothing on this page is transmitted to the county. Print it, sign it, and deliver it as the form directs.