Name Of Applicant

Mobile Number

Address Of Applicant

E-Mail

State

City

Apply To

Is the Utility to be taken along And/Or across the road?

Along The Road

Across The Road

District

Division Name

Road Name

Utility to be taken on Which Side?

Left Hand Side

Right Hand Side

Distance of Utility from Center Line of the nearest carriageway(Meter)

Kilometers of the Road at the crossing if the Utility is crossing the Road

Category Of Utility To be Laid

Length(in KM)

Width of Road(Meter)

Chainages(From-To) in KM

Along the Road(Meter)

Across The Road(Meter)

Is it proposed to lay the Utility across the Road through casing pipe? Yes No

Diameter Of Casing Pipe(Meter)

Type of Casing

Depth at Which Casing Pipe id to be laid(Meter)

Are Inspection Chamber proposed at the end of Casing Pipe? Yes No

Location of the Inspection Chamber from the center of the carriageway

Size of Inspection Chamber