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Permit # DRIVEWAY AND ROAD APPROACH PERMIT DAWSON COUNTY DEPARTMENT OF PUBLIC WORKS NAME: PHONE EMAIL ADDRESS: THIS IS A PERMIT TO CONSTRUCT AN ACESS DRIVEWAY ON THE FOLLOWING COUNTY MAINTAINED ROAD: MAP PARCEL ID NUMBER: _ Applicant declares they are the owner of the real property abutting the above described county road and has the lawful authority to apply for this permit. The applicant agrees to the provisions, guidance, and specifications of the Dawson County Driveway Ordinance. APPLICANT SIGNATURE: DATE: Installation Requirements as Follows (please fill out, as required): Driveway Type: ☐Residential ☐ Residential (Common Access) ☐ Commercial Surfacing Details: ☐Gravel Driveway ☐ Asphalt Driveway ☐ Concrete Driveway ☐ Other PUBLIC WORKS USE ONLY CULVERT REQUIRED: SIZE: CULVERT MATERIAL: HDPE RCP ☐No culvert required AT THIS TIME. However, any deviation from this permit shall be inspected by the Dawson County Public Works Department and could require new permitting. Notes: _ Date of Application: Final Inspection Date: Inspector: By: PW Employee Signature: ☐Approved ☐ Denied Dated this day of , 20 ☐Approved ☐ Denied ---PAGE BREAK--- A detailed plan (sketch, map, or site plan) of the driveway shall be shown below (or attached) as part of this application and shall be made a part of this permit. Drawing Explanation (if Add Attachment