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"move" <br />Sam FORM 11367-431, (csoRCIA DIV. ONLY) (Pw, y? <br />APPLICATION FOR PIPELINE AGREEMENT > <br />PPLICANT.MUST ANSWER ALL QUESTIONS AND RETURN THIS FORM TO: I.D. No. <br />Date Issued: <br />DEPARTMENT Real Estate E Contract Services <br />STREET 600 West Peachtree St., NW, Suite 1650 <br />CITY, STATE, ZIP Atlantan, GA 30308.3603 <br />PHONE 404 52$( <br />l: Legal Name of Applicant (party to agreement); County of Orange <br />(Please state street address:) 4. Billing Address: <br />.Street 200 South Cameron Street <br />Street P. 0. Box 8181 <br />City Hillsborough State NC p 27278 CAY u h State NC Zip 272 <br />I. Name of Applicant Representative: S. Name of Contact for <br />Billing purposes: <br />Paul Thames Paul Thames, P.E. <br />Title: Count Engineer Title. County Engineer <br />Telephone Number( ) 919-732-8181 Telephone Number( ) 919-732-8181 <br />i. Billing: Applicant prefers ( ) yearly (70 one-time non-assignable payment. (See Page 3) <br />'. Applicant is a: ( ] Corporation - Give state of formation: <br />( I Limited Partnership - Give state of formation: <br />( ] Genera! Partnership - Give state of formation: <br />( J Sole Proprietorship -- Give name of owner: <br />( ] Individual <br />1X I Government Entity <br />( J Other. <br />1. Location of Pipeline: <br />A. Nearest Street Redman Crossing B. Nearest Town Mebane <br />C. County Orange D. State North Carolina <br />. <br />E. Railroad Milepost Reference: 3300 ft. N E S R of H-36 <br />(Circle one <br />F. Will pipeline be located entirely within confines of public street? ( , ;s ( ] No <br />It yes, provide conclusive evidence for verification. <br />Street width: 20 ft. Street Right of Way width: 60 h. <br />1. Pipelige ( X] is to be installed ( ] already exists and is being upgraded <br />Are there any agreements covering the pipeline? ( J Yes IX I No ( I Do not know <br />It yes, identity and attach copies- <br />!. The pipelire will: (check all appropriate boxes) <br />( X] Cross tracks - How many? 1 <br />( I Cross communication and/or signal lines - Separation ft. <br />[ I Parallel Tracks - Minimum horizontal distance to centerline of adjacent track it. <br />( X) Be underground - Depth below base of rail 9.0 ft. Minimum depth on right of way 3.0 <br />( j Be aerial - ft. above top of rail <br />Identify facilities on Railroad right of way (manholes, pipe bridges, etc.): Public roadway; 12" waterline, P' <br />. cable; gas line, signal cables, over ea electric lines <br />(Continued on other side)