1
W E S T P E N N T O W N S H I P
OF SCHUYLKILL, COUNTY, PENNSYLVANIA
27 Municipal Road, New Ringgold, PA 17960
570 386-4507 Township Office 570 386-1100 Police 570 386-5851 Fax
APPLICATION FOR TOWNSHIP ROAD OCCUPANCY PERMIT
GENERAL INSTRUCTIONS
*Any work performed within the Right-of-Way of a Township road requires submission of three (3) copies of this form along with three (3) copies of a sketch showing location and details of proposed work.
*Any work performed on a Township road over, under, or within, the limits of a
limited access state highway, requires a state permit.
*The prescribed permit fee shall accompany the application(s) and sketch.
*Fee shall be paid by check or money order, payable to West Penn Township.
*Application & fee to be delivered to Township at 27 Municipal Road, New Ringgold, PA 17960
A P P L I C A N T T O C O M P L E T E (Please Print):
NAME OF APPLICANT: ______Phone # (_____) _____ - ______
Cell # (_____) _____ - ______
Fax # (_____) _____ - ______
ADDRESS OF APPLICANT: ______
______
Applicant is (an individual (a partnership) (a corporation incorporated under the law of ______)
(Corporate Seal)
Signature: ______
(Executive Officer or Authorized Representative)
ROUTE NUMBER, ROAD, STREET, OR DRIVE NAME WHERE WORK IS TO BE DONE:
______
DESCRIPTION AND PURPOSE OF WORK: ______
Under and subject to all the conditions, restrictions, and regulations prescribed by the Township.
OVER PLEASE
D A T A A P P L I C A B L E T O T H I S A P P L I C A T I O N
GENERAL Approximate date when work will begin ____/_____/____
Approximate date when work will be complete ____/____/____
Road surface is improved to a width of ______feet
Distance from center of line of roadway to gutter or ditch ____ feet
Distance from center-line of road to Right-of-Way line ______feet
POLE(S) AND TOWER(S) Number of Structure(s) (pole, tower, etc) to be erected: ______
Nearest distance from center of road to structure: ______feet
Distance of proposed work along the road _____ feet
PIPE(S) LINE(S) AND CONDUIT(S) Improved road will / will not (circle appropriate one) be opened.
Approximate area of openings in improved surface: ______sq yds.
Approximate area of opening on unimproved part: ______sq yds
Length of trench along road: ______sq yds
Depth of trench below surface: ___ inches
S C H E D U L E O F F E E S
SCHEDUE ITEM FEE
ITEM #
459.4A1 Issuance Fee $50
Underground Facilities (Each 100 ft Increment)
459.4b1 Opening in Pavement $30
459.4b1 ` Opening in Shoulder $15
459.4b1 Opening Outside Pavement and Shoulder $10
Surface Openings (Less than 36 S.F.)
459.4b2 Opening in Pavement $30
459.4b2 Opening in Shoulder $15
459.4b2 Opening Outside Pavement and Shoulder $10
Above Ground Facilities
459.4b3 Poles, Guys/Anchors Installed Independently
(Up to 10 Physically Connected) $20
459.4b3 Additional Connected Facilities $2
459.4b3 Crossing (Tipples, Conveyors, Walkways etc) $80
C A L L B E F O R E Y O U D I G ! 1 8 0 0 2 4 2 - 1 7 7 6
T A B U L A T I O N
Schedule Item # ______Unit Fee ______# of Units ______TOTAL FEE ______
Schedule Item # ______Unit Fee ______# of Units ______TOTAL FEE ______
Schedule Item # ______Unit Fee ______# of Units ______TOTAL FEE ______
Schedule Item # ______Unit Fee ______# of Units ______TOTAL FEE ______
TOTAL FEE $ ______.00
NOTE: Application is not complete unless appropriate fee accompanies application form.