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� <br /> I <br /> APPLICATION FOR PIPE LINE PERMIT �BURIJNGTON <br /> � NOKfHERN <br /> To BURLINGTOM NORTHERN INC. Date �" �' � ���" — <br /> ! <br /> 1. At what City or Village is permit desired� �'��f/+�t T� <br /> 2. Fuil name and address of Appiicant C�/rj �`F L- 6'i-/�CT/ /�l/,6'!/.4' C�O.rl/s S' <br /> ���'�' L�r"Oi,�it sY/1 . �%v�i1i=!: G:.,f • <br /> 3. If Applicant is a corporation, in what s[ate incorporated7 ��i�S'rii NC T�1� <br /> If an individual, under what firm name is business conducted7 <br /> If partnership, give name oi all partners <br /> 4. Product to be handled in pipe line -t�Tr>,y.�y �/�/)/N <br /> 5. Pipe Data: CARRIER PIPE CASING PIPE CARRIER PIPE CASING PIPE <br /> a. Outsidediameter ��� �,P` f. Actualworkingpressure �� L`''" <br /> b. Inside diameter �' _ /�f' g. Type of join[ ���8��' �'"�'�E-r wi� ak i� <br /> c. Pipematerial �'��Nf��`��� r�«'�- h. Coa[ing '����-z— /�/�i^'%— <br /> d. Specifications i. Method of installation <br /> and grade j, Will cathodic protection <br />� e. Wall thickness �" Se" ._ , `i�� be provided? �I``� �— <br /> � � <br /> 6. a. Depth of pipe under track (rop of tie to bottom of casingl� 7� C <br /> b. Angle of crossing �C ` <br /> 7. If pipe is to be placed longitudinally with track,give <br /> a. location of pipe in relation to centerline of nearest track <br /> b. depth of coverage (ground line tn top of pipe� _ <br /> 6. If installation is to b^by�acking or boring method give location of jacking and receiving pits <br /> a. Depth i <br /> b. Distance facing wall of pit to centerline of nearest track (measured normal�_ �^ <br /> 9. Reference plans(ro be forwarded with original application� <br /> a. Drawing Number b.Prepared by <br /> Applicanf ag�ees that il installafion iequires any o� all of the !ollowing wo�k; removal and replacement of track, bridging, <br /> protection of track or other railway tacifities by wnrk or flvgging,engineering and/or supervision;such work is[o be per(ormed <br /> by railway employes and the cost borne by Applicant. 11 in the opinion of the Railway Company suf/icient haza�d is involved <br />� the Applicant will be requi�ed to fumish liability and property damar�e insurance in form and amounts satislacrory to <br /> Burlingto orthem. <br /> BY'-___,��r�"I� - -GvI1 �ccl,liLL� <br /> � pplicant) �TA le) <br /> !/ <br />� RECOMMENDATIONS: (If additional �ace is required attach supplemental sheet) <br /> Date �g <br />. APPLICATION APPROVED: , <br /> ISuperintendent) �a <br /> (AssL Vico President-0perotionsl <br /> (General Manogor Leasa5) (F7ugional Monoger Enginecring) <br /> FONM 16007 1•73 Printecl(n U.S.A. <br />� � <br />