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Date: ___

Application Made By: ___

Address: ___

Contact Person: ___

Telephone Number: ___

Contractor: ___

Contractor's Address: ___

Contractor's Phone Number:

Road Opening Location:

(Please give details, i.e. roads, distances)

Purpose of Road Opening: ___

Start Date: ___ End Date: ___

Feet Width (Maximum) x ___ Feet Length (Maximum)

Size of Opening:

Application Fee (non-refundable):

$ ___

Inspection Fee (non-refundable):

$ _____

Restoration Guarantee (to be returned upon final acceptance): $___

___

Proof of Insurance Provided (Yes/No):

The applicant acknowledges and understands that all work performed under the terms and conditions of this permit shall be in accordance with the Jackson Township Code Part II: General Legislation, Chapter 372 "Streets and Sidewalks", Article III "Street Openings".

Applicant's Signature: ___

Date: ___

Return Application to Public Works Office or email to: recycling@jacksontwpnj.net

TOWNSHIP OF JACKSON

Dept. Of Public Works: 732.928.1311