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'0�a #J"r City of South Bend Public Works Phone: 574.235.925 i <br />a1 . Engineering Division <br />Email: dha <br />nson@southbendin.gov <br />ov <br />,. '10 227 W. Jefferson, County City Building 1316 g <br />�1 South Bend, IN 46601-1830 <br />r. <br />m <br />N <br />Date Submitted: <br />lonstrtn°:lloins: 1) Print Clearly 2) Complete All Sections <br />Suburff: 1) This Form In Person 2) Or Email To: v <br />3) Upon Permit approval: Sign issued permit and Return <br />"Contractor is responsible for associating their company Project # with CSB Permit # for invoicing" <br />Incomplete Submittals Cannot Be Processed <br />Applicant Honeywell International <br />(Contractor/Company Name) <br />Contact Name Email Chuck.GwAWmann@honeywell.com <br />Phone Number 763-954-5418 <br />Street Address I Location of Work 2700 Bertrand Street, South Bend, Indiana <br />Dim QLWPA Cable 11 Electric Fiber [:] Gas Manhole repair <br />Sanitary Sewer 0 Water R] Other Remedial Well Installation <br />Lbw . <br /># Cuts <br />In Street <br />Comments I Description of Work <br />0 Boring 1:11 Trenching (open). .. I 1 11 # Feet <br />ZOutside curb, but in treelown/sidewalk Right of Way <br />Date I Duration of project June/July -2wks (eg: 2/1/18, 2 hrs) <br />Honeywell Intemational (Honeywell) requests permission to install a remediation pumping well <br />within the tree -lawn area along the south side of the east bound lane of Bertrand Street, <br />200 feet east of Bertrand Street and Eclipse Dr (41.681486 N, 86.288188 W) <br />Excavation in ROW without a permit will result In stop work order and/or delays In perms ing. <br />Emergency excavations must be phoned Into the Permit Office no later than NOON the following day. <br />THIS EXCAVATION PERMIT REQUEST IS NON -TRANSFERABLE AND A SIGNATURE SUBJECTS THE NAMED CONTRACTOR/PERMITTEE <br />TO ALL APPLICABLE RULES, DUTIES AND OBLIGATIONS IMPOSED BY THE CITY OF SOUTH BEND MUNICIPAL CODE AND TO ALL <br />REGULATIONS IMPOSED BY THE SOUTH BEND BOARD OF PUBLIC WORKS. <br />Applicant Signature Date �o Zl / -Z-0 ( r <br />EXCELLENCE ACCOUNTABILITY INNOVATION INCLUSION EMPOWERMENT <br />v 1.5.18 <br />