Permit No.  S

District No.

MESA COUNTY ENGINEERING DEPARTMENT
MESA COUNTY, STATE OF COLORADO
SURFACE ALTERATION PERMIT (SAP-1988)

PERMITTEE'S NAME:	DATE:
ADDRESS:
PHONE :

Your request for permission to commence construction within the Mesa County road right-of-way of Road Name/Number ____________________________ at Street Address: ___________________________________________ is granted subject to the following conditions:

IT IS UNDERSTOOD that the Permittee will perform all phases of construction at no expense whatsoever to Mesa County and that the Permittee will be responsible to provide all certification tests as required by the Mesa County Standard Specifications for Road and Bridge Construction.

Materials for embankments and subgrades obtained from cuts or borrow areas shall be free from detrimental qualities of organic material, such as leaves, grass, roots and sewage. 

Embankments and subgrade compaction shall not be less than 95% of the maximum density per AASHTO T-99, unless otherwise specified in the special conditions of this permit.

Permittee shall be responsible for a period of 18 (eighteen) months after completion.

SPECIAL CONDITIONS:
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This work shall be completed within ______________________ from the above date.  Normally no work shall be allowed on Saturday or Sunday unless specified in the Special Conditions.  No open trenches or hazardous obstacles shall be permitted in or adjacent to the traveled roadway after dark, unless otherwise specified in the Special Conditions.

The traveling public must be protected during all phases of construction with proper warning signs, barricades and/or channeling devices.  These warning devices shall be used to warn and alert the motorists of hazards created by construction activities in or near the traveled roadway.  Warning devices shall be installed by, and maintained at the expense of the Permittee and in accordance with the Manual of Uniform Traffic Control Devices for Streets and Highways.  Warning devices shall be placed in positions where they will convey their messages most effectively so that the drivers will have adequate time for response, both day and night.

MESA COUNTY ENGINEERING DEPARTMENT

By: ___________________________________
Engineering Department Coordinator       

In accepting this permit the undersigned, representing the Permittee, verifies that he has read and understands all the foregoing provisions and conditions; that he has authority to sign for and bind the Permittee; and that by virtue of his signature the Permittee is bound by all the conditions set forth herein.

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Permittee Signature

PLEASE PROVIDE A SKETCH OF PROPOSED PROJECT