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3. ADA Access Service Request for County Maintained Roads
   Do you have an accessibility problem with a county maintained road? Use this form to report a problem. After submitting the form, it will be distributed to both the Department of Public Works as well as the County's ADA Coordinator. The first thing staff will do is verify if the problem is on a County maintained road.
5. Not an ADA accessibility issue? Looking to report a pothole?
   Request for Service on County Maintained Roads Form (Potholes, etc...)

   If the problem is a road maintenance issue (such as a pothole) and not an ADA accessibility issue, please use the Request for Service on County Maintained Roads Form. The link is above.
7. If the problem is not on a County maintained road,
   the Department of Public Works will advise you to contact the party responsible for that road.
9. If the problem is on a County maintained road,
   your request will be investigated and a plan to resolve the problem will be put in place. In some instances, such as vegetation growing over the sidewalk, the fronting landowner will be notified of the problem and is obligated to resolve the problem. In some instances, such as a utility pole blocking passage, the utility company will be notified and is obligated to resolve the problem. In other instances, such as a problem with the curb ramp, the County is responsible for addressing the problem.
10. 
12. In addition, if the Department of Public Works is not clear about what the problem is,
    staff will contact you to discuss your concerns; therefore it is helpful if you provide the County with your name and contact information. Some problems such as having vegetation trimmed or trash cans removed can happen fairly quickly. Other problems such as constructing a curb ramp may take a significant amount of time.
14. Have questions?
    Please call the Department of Public Works ~ Road Maintenance Division at 707.445.7421
16. Need help with Americans with Disability (ADA) Title II Regulations?
    https://www.ada.gov/regs2010/titleII_2010/titleII_2010_regulations.htm

    This is a link to the ADA regulations set forth in 28 CFR Part 35. This link will open in a new window.
18. Please complete one form for each site.
22. What is the name of the road where the problem is located?*
24. What is the specific problem?*

    Check ALL boxes that apply:

    1. The sidewalk is obstructed by vegetation
    2. The sidewalk is obstructed by a permanent object such as pole, post, mailbox, utility, etc.
    3. The sidewalk is obstructed by a movable object that can be moved out of the way such as a trash can, portable basketball hoop, etc.
    4. The sidewalk is damaged/broken/uplifted
    5. There is no sidewalk at this location
    6. There is a problem with the curb ramp at the intersection
    7. There is no curb ramp at the intersection
    8. There is a problem with the cross slope of the sidewalk at this location
    9. The driveway apron makes the sidewalk inaccessible
    10. Parked vehicles are blocking the sidewalk
    11. There is a problem with the painted crosswalk lines
    12. There is a problem with the pedestrian push button at a traffic signal
    13. There is a problem with the audible pedestrian signal (APS) at a traffic signal
    14. There is a problem with a transit bus stop
    15. There is a problem with a school bus stop
26. Please describe the problem.*
    Tell us what the problem is and what you think the County should do to fix it.
28. OPTIONAL: Do you have any photographs of the problem that you would like to submit?
    If you have photos of the problem you may include them. Click the BROWSE button to upload photos.
32. Where is the problem located at?

    1. I will enter the location of the problem using Google Maps Coordinates (PREFERRED)
    2. I will enter the location of the problem using the Assessor Parcel Number
    3. I will enter the location of the problem using a Street Address

    The County needs to know exactly where the problem is. Without knowing where the problem is, we cannot work to address the problem. There are 3 ways to identify the location of the problem area. The most accurate way is using google maps coordinates. The second most accurate way is to provide an Assessor Parcel Number. The third way is by providing an address. Please consider using the google map coordinates as it provides the County with the most accurate location. Instructions for finding coordinates or the Assessor Parcel Number will be shown when you select the appropriate option.
34. Please paste the latitude and longitude from Google Maps*
    (Example: 40.780407, -124.161374) Instructions: Using Google Maps, insert a Placemark at the location where the problem is located. Copy and paste the coordinates into the cell below. For help use the link below for the Google Maps Help File.
36. Google Maps Help File
    https://ca-humboldtcounty.civicplus.com/DocumentCenter/View/58893
38. Please enter the Assessor Parcel Number (APN)*
    Instructions: The APN is a 12 digit number. (Example: 404-023-018-000) You can find an APN using the County's Geographic Information System (GIS). The link to the GIS is shown below.
40. Humboldt County Geographic Information System (GIS)
    http://webgis.co.humboldt.ca.us/HCEGIS2.0/

    Click the link to open a new window with the County's GIS
42. Please enter the complete Street Address where the problem is located*
    (Example: 1106 Second Street, Eureka)
46. What is your contact information?
    We require your name and telephone number or email address in case we need to contact you regarding the problem. If we cannot find the problem, then we can't fix it. If you don't have a phone number, please provide us with your email address or mailing address.
48. What is your name?*
50. What is your telephone number?*
    If you do not have a telephone, please enter 555-555-5555
52. What is your email address (OPTIONAL)?
    If you don't have a telephone number, please enter your email address. If you don't have a telephone number or an email address, please enter your mailing address.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field