TOWN OF HORSEHEADS HIGHWAY DEPARTMENT

150 WYGANT ROAD

HORSEHEADS, NY  14845

APPLICATION FOR EXCAVATION INTO TOWN OF HORSEHEADS ROADS

APPLICATION # __________________                             DATE __________________

Application is hereby made by the undersigned to the Town of Horseheads for permission to make an excavation in the following Town Road for the purpose to connect:  sewer ______ water ______ other ______.

Said excavation is to be made in accordance with the specifications and reequrements of the Town of Horseheads Highway Superintendent.

Property location _______________________________________________________________________

Will enter road_____ Will not enter road_____

Date work being performed_______________

Owner _____________________________________________

Tax Map I. D. # ______________________________________                  Major# ___________________

Applicant ____________________________________________________

Company ____________________________________________________

Address _____________________________________________________

Phone # _____________________________________________________

Liability Insurance on file __________ Expires ______________

Workers' Compensation Insurance proof on file _________ Expires _________

CALL UFDO TWO WORKING DAYS BEFORE YOU DIG!

1-800-962-7962

Issued by __________________________________________

Kevin Smith, Highway Superintendent