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PROJECT REQUEST FORM
PLANNINGBUILDING/PUBLIC WORKS
DATE: Zq O (� CONTACT:
EXT.
FILE STATUS ❑NEW OR ❑ EXISTING: FILE CODE(Ptu-XX-XXXX):
LOCATION ❑ My Work Space:
❑ File Bay Shelf#: ❑ Other:
PROJECT NAMEVI FILE TITLE: 2 2
(70 characters max)
DESCRIPTION OF PROM
UTILITY PERMIT# (1� v LUA#
' / / WO#
ADDRESS/STREET NAME(S):_ 3 2 9 /V W
DEV: CNTTZ
OWN: ; CNSLT/ENG:
OTHER ALIASES: �,�,� /,� {mil,✓ Z S
U l�
Circle Size of Waterline: 81, 10" 12"
Circle Size of Sewerline: g Circle One: New Replace Extension
" 10" 12" Circle One: New/Replace Extension
Circle Size of Stormline: 12" 18" 24"
Circle One New/Replace/Extension
CHECK EACH DISCIPLINE INVOLVED IN,PROJECT
Ltr Drwg #of sheets
N"�'TED
(off site improvements)
❑ TRO (include TESC)
(Signalization,Channelization,Lighting) ❑ ❑
WWP
(sanitary ❑ El
q� sewer main,include basin name)
WTR
(Mains,Valves,Hydrants) ❑ . ❑
S WP
(inc.composite&HorizontalCtrl)
m
(CIP onlyXinclude basin name) El
❑
PLR (For Developer Files Only) ❑ (letter only)
PLEASE CIRCLE THE DISCIPLINES WffiCH NEED TO SIGN MYLARS
WATER WASTEWATER SURFACE WATER
TRANSPORTATION FIRE
FOR FILE AIAINTAINANCE USE ONLY
File Codes File Alias
s 4 Date Entered and Labels Made
f ! 41