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s~ ~ ~~ FORM 11367-GA (GEORGIA OIV. oNl1~ (pay, yy~ ( <br />APPLICATION FOR PIPELINE AGREEMENT >.s <br />I.D. No. <br />PPUCANT•MUST ANSWER ALL QUESTIONS ANO RETURN THIS FORM T0: Oate Issued: ! ! _ <br />OEPART1r1ENT Aeat Estate S Contnet Servicas <br />STREET 600 West Peae~ttrN St., NW, Suite 1650 <br />CITY, STATE, 21P Attants, GA 30308603 <br />PHONE 40t SZ9~,~~j9 <br />t : Legal Name of Applicant (party to agreementj: County o f Orange . <br />(Please state street address:) 4. Billing Address: <br />. Street 200 South Cameron Street Street p • O , Box 8181 <br />. City Hillsborough State N~Zip 27278 City-Hillsborough State NC Zp 27278 <br />1. Name of Applicant Representative: <br />Paul Thames <br />Tale: County Engineer <br />Telephone Number.( ) 919-732-8181 <br />Corporation -Give state of tomnation: <br />Limited Partnership -Give state of formation: <br />i. Billing: Applicant prefers ( )yearly (X) one-time non-assignable payment. (See- Page 3) <br />'. Applicant is a: <br />f. Location of Pipeline: . <br />A. Nearest Street Redman Crossing <br />C. County <br />( ] General Partnership -Give state of formation: <br />( ] Sole Proprietorship -Give name of owner: <br />( ] Individual <br />(X ] Government Entity <br />5. Name of Contact for Bitting Purposes: <br />Paul Thames, P.E. <br />Title: County Engineer <br />Telephone Number: ( ) 919 - 7 3 2 - 8181 <br />( ] Other. <br />Orange <br />D. State North <br />N E S ~of <br />(C1rds one <br />Carolina <br />..:st H-36 <br />B. Nearest Town _ <br />Mebane <br />E. Railroad Milepost Reference: 3300 f t . <br />F. Will pipeline be located entirely within confines of public sUeet? ( ~s ( ] No <br />tf yes, provide contusive evidence for verification. <br />Street width: 20 it. Street Right of Way width: 60 h, <br />Pipeline (X( is to be installed ( ]already exists and is being upgraded <br />Are there any agreements covering the pipeline? ( ]Yes ()(] No ( ] Do not know <br />tt yes, iCentity and attach copies: <br />. The pipeline will: (check a!t appropriate boxes) <br />(XJ Cross tracks -How many? 1 <br />( ]Crass communication and/or signs! tines -Separation ft. <br />( ] Parat!el Tracks -Minimum horizontal distance to centerline of adjacent track h. <br />(X] Be underground - Oepth below base of rail 9.0 K. Minimum depth on right of way 3.0 g, <br />( ] Be saris! - ft. above top of rail <br />ublic roadway; 12" waterline, phone <br />. Identity facilities on Railroad right of way (manhdes, pipe bridges. etc.): <br />cable; gas line, signal cables, over ea electr c Ines <br />(Continued on other side) <br />