Minimum Use Driveway Application

First Name *

Last Name *

Address *

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Phone

Email *

County *

Municipality *

Route #

Name of Nearest Intersection

Distance to Nearest Intersection (ft)

Application is made to
Construct a new drivewayAlter an existing driveway

Is any portion of the property reserved for a person with a disability or a severely disabled veteran?
YesNo

Work Start Date *

Work Completion Date *

1 - Posted Speed Lmit (mph)

2 - Roadway Sight Distance (ft)

3 - Roadway Sight Distance (ft)

4 - Driveway Radius (ft)

5 - Driveway Radius (ft)

6 - Driveway Width (ft)

Under the subject to all the conditions, restrictions, and regulations prescribed by the Pennsylvania Department of Transportation on the issued Permit, Form M-945P. The applicant certifies that all statements contained herein are true and correct.
Applicant Signature: