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2. Date:*
   Date:
4. Property Owner:
5. First Name*
6. Last Name*
8. Address1*
10. City*
11. State
12. Zip
14. Phone No. *
15. Email Address*
17. Please describe driveway improvement to be made: (Example: Surface replacement, change of grade, gutter/curb change)*
19. PLEASE NOTE: Portion of driveway surface meeting road curb should be same height as top of curb when improvement work complete.
21. Date work scheduled to begin:*
22. ** Three (3) working days minimum notice required to schedule a site review **
24. Will roadway curb or water flow line be altered in any way?*

    1. Yes
    2. No
26. If yes, please explain:
28. TOWNSHIP ORDINANCE #379, CODE 611.8 - "Driveway may extend from the right-of-way line of the street to the cartway of the street, but shall not change the grade or contour of the street right-of-way, nor shall any person cut into, fill, or in any way alter any gutter, curbing, drainage ditch, or storm water sewer within the right-of-way of a street or easement without first obtaining a permit (at no cost) from the Township". **Sanitary sewer vents/clean-out vents must be a minimum of one (1") inch above driveway surface **
30. By submitting this form verifies that I have read and understand the DRIVEWAY IMPROVEMENT CODE and agree to perform all driveway improvement work in full compliance of it.
32. TOWNSHIP USE ONLY
34. Date Received:
35. Date & Time of Site Review
37. Site Reviewed By:
38. Action Taken:

    1. Approved
    2. Denied
40. Comments:
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field