TOWN OF GOSHEN
GOSHEN, CT 06756
ROAD EXCAVATION APPLICATION & PERMIT
Permit # _________________________________ House # _____________________________________________
The undersigned hereby applies for a permit to open by excavation a road or street in the Town of Goshen as follows:
Work being done for (homeowner)__________________________________________________________________
Road or Street ________________________________________________________________________________
Linear feet of excavation ________________________________ Depth__________________________________
From Utility pole number_____________________________ to Utility pole number __________________________
Total square feet of surface_________________________________________________________________
Purpose ________________________________________________________________________________
Contractor:_________________________________________ Address:___________________________ (PLEASE PRINT)
Telephone # _______________________________________________ FAX # _______________________
Start date _________________________________Expected end date ________________________________
Dated at Goshen, Connecticut, this _______ day of ________20_____.
Dated______________________ By ________________________________________________ (Signature of contractor)
CALL BEFORE YOU DIG # ________________________________ WLSD PERMIT #_____________________________
Approval is hereby given to ______________________________________________________________________ to excavate and open _________________________
in the Town of Goshen in accordance with and to the extent described in the foregoing application. This permit may be revoked at any time in the discretion of the Selectmen
of the Town for failure to comply with the conditions thereof or failure to complete the work and restore the highway to its original condition by the specified date of termination.
Dated:__________________________________ By:_______________________________________________
Public Works Supervisor
TOWN OF GOSHEN
RE-INSPECTION
Approval is hereby given for the release of the surety (license & permit) bond.
Dated:_______________________________ By:_________________________________________________ Public Works Supervisor
TOWN OF GOSHEN
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