WALLOWA COUNTY, OREGON

PERMIT APPLICATION FOR EASEMENT

Within County Road Right of Way

Name of Applicant: ________________________________________________________________________

Last First Initial Phone #

Address: _________________________________________________________________________________

Street or P.O. Box City State

County Road No. __________________________________________________________________________

From County Road Index Map

Location on County Road: __________________________________________________________________

__________________________________________________________________________________________

(Distance in feet or miles North, South, East, West from nearest intersection, house, waterway)

Description of work or project for which permit is required: ______________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

(If for cattle guard or pipeline, refer to County Standards covering same)

Estimated time project will begin: (Date) ______________________________________________________

Estimated time of completion: (Date) _________________________________________________________

Will work be contracted: Yes __________ No ___________

If contracted, by whom: ____________________________________________________________________

(I)(We), the undersigned applicant(s) do hereby agree that all costs and disbursements connected with this work or project as herein above stated will be borne entirely by the applicant and that no cost in connection therewith shall accrue to Wallowa County, that all cleanup, damage, and repair to the County Road shall be done by the applicant in such a manner as will be approved by the County Road Superintendent, that Wallowa County shall be held harmless from any liability arising from the actions, deeds, or neglects of the applicant in connection with the above project. It shall also be agreed that any recommendations by the County Superintendent and County Board of Commissioners shall become a part of this application and shall be binding upon the applicant and shall become a part of the permit, if granted. It is further agreed that in the event of the re-location, betterment, or re-construction of said County Road and it becomes necessary to re-locate or remove any improvements done by applicant in connection with this application, the cost of such relocation or removal shall be borne by the applicant. Applicant further agrees that any improvement made upon said County Road in connection with this permit will be kept in good repair so that no damage to the County Road will occur and that travel over, along, or across such improvement will not be impeded. In the event that the stipulations mentioned herein are not fulfilled by the applicant, in full or in part, or if said work is not completed prior to one (1) year from date of issue, this permit shall become null and void and may be revoked by the County Board of Commissioners with all costs of removal of any improvements from the County Road right of way being charged to applicant, his heirs, or assigns.

Applicant’s Signature __________________________________

Date _________________________________________________

(Do not write below this line)__________________________________________________________________

Road Superintendent’s Recommendations: ____________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I (do) (do not) recommend that the Board of Commissioners grant the above permit.

Date: _______________________________________ Signed: ______________________________________

Road Superintendent

ACTION OF BOARD OF COMMISSIONERS

Further Recommendations: _________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

The matter of the Application for Permit by the above named applicant having been presented before the Wallowa County Board of Commissioners during (regular) (special) session it is hereby ordered that the above application be (approved) (disapproved) and that a permit (is) (is not) granted herewith.

__________________________________________

County Chair

__________________________________________

Commissioner

________________________________ __________________________________________

Date Commissioner