EmailMeForm
Must be completed by Utility Company
Utility Company Name
*
Representative Name
*
Utility Company Address
*
City
*
Zip Code
*
Email
Daytime Phone
*
Cell Phone
*
WORK TO BE PERFORMED WITHIN RIGHT-OF-WAY
Location where work is to be performed:
Type of Utility
Gas
Electric
Phone
Cable
Other
Type of Work
Overhead Line Parallel to Road
Overhead Line Crossing Road
Underground Line Parallel to Road
Underground Line Crossing Road
Utility Pole Installation
Tree Trim/Removal
Access Drive (describe below)
Other
Detailed Description
(as needed, add attachment if necessary)
File Upload
jpeg, jpg, tiff and pdf
Work will commence on or about
MM
/
DD
/
YYYY
Will require # of days to complete
enter # of days
SERVICE PROVIDER PERMIT REQUIREMENTS
I agree to comply with all conditions, restrictions, and regulations of the Fairfield County Engineer. If compliance is not met in the opinion of the Fairfield County Engineer, it is understood that the County Engineer reserves the right to stop work being performed and restore the right-of-way to an acceptable condition at the expense of the applicant. I am authorized to complete Right-of-Way Application.
*
YES
PLEASE ENTER FULL NAME:
*
Signature
*
Clear
