2. EXCAVATION PERMIT

4. PROJECT INFORMATION

6. Project Address*
8. Description of Work Proposed:*
10. File Upload (maps, photos, etc.)
12. Type of Work Being Performed: SANITARY LATERAL REPAIR, INSTALLATION OR DISCONNECTION*

    List Number of Excavations (enter 0 if not applicable)

14. Type of Work Being Performed: WATER SERVICE REPAIR, INSTALLATION OR DISCONNECTION*

    List Number of Excavations (enter 0 if not applicable)

16. Type of Work Being Performed: DIRECTIONAL BORING*

    List Linear Feet (enter 0 if not applicable)

18. Type of Work Being Performed: OTHER*

    List Type of Work Being Performed AND List Number of Excavations or Linear Feet (enter 0 if not applicable)

20. Start Date of Project (estimated)
    Start Date of Project (estimated)
21. Completion Date of Project (estimated)
    Completion Date of Project (estimated)

23. APPLICANT INFORMATION

25. ALL WORK MUST CONFORM TO THE CODES OF THE CITY OF ROCK ISLAND

    I hereby certify that I have the authority to make the forgoing application, that the information given is correct, and that all construction will comply with the International Codes and applicable ordinances of the City of Rock Island.  I also understand that it is my responsibility to contact the Engineering Division for applicable inspections when the area is ready to be poured.

27. Company Name*
29. Applicant Name*
31. Applicant Address*
33. Applicant Phone*
34. Applicant Email*
36. As the Applicant for this permit I certify that I am the (must check one) for the address where above work is being conducted.*

    1. Property Owner
    2. Contractor
    3. Authorized Agent
38. City of Rock Island Construction Standards
    City of Rock Island Construction Standards
40. I have read and will follow the City of Rock Island's Construction Standards.*

    1. Yes
    2. No

42. Call JULIE before you dig.  Call 811 or 800-892-0123 for locate requests.

Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit Submit and Print

* indicates a required field