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Annual Encroachment Permit Holder Project Notification Form & Emergency Work Notification Form

  1. 2016 County Logo 600

  2. Annual Encroachment Permit Holder Project Notification Form & Emergency Work Notification Form

    Holders of an Annual Encroachment Permit (AKA "Special Permit") shall notify the Department when performing work in the County right of way under the annual permit. [Reference: County Code 411-11(j) and (l)]. Anyone performing emergency work within the County right of way shall notify the Department of Public Works. [Reference: County Code Section 411-11(a)] Submital of this form electronically on the County website shall be used to notify the Department of Public Works - Land Use Division of work done under the annual permit or to report work done in an emergency. Reporting is to be done prior to working in the right of way; however it is understood that due to unforeseen circumstances there may be an occasional need to report work after the work has been completed. Please report all work in a timely manner.

  3. *** THIS IS NOT A PERMIT ***

  4. 3. Is this Emergency Work?*

    Select the type of work being done

  5. 3A. Party performing the work*

  6. Project Location (Google Maps Coordinates):

    Using Google Maps, insert a Placemark at the location where the project work will be done. Copy and paste the coordinates into the cell below. (Example: 40.780407, -124.161374) For help use the link below for the Google Maps Help File.

  7. Paste the latitude and longitude from Google Maps. Example: 40.780407, -124.161374

  8. 6. Type of Work:*

  9. 7. Work Location:*

    Check ALL boxes that apply:

  10. 8. Will the work require the road surface or sidewalk to be restored/repaired?*

  11. 9. Will the work result in the placement of facilities in, on, or above the sidewalk area?*

  12. Note: You do not need to submit a new form if the actual work dates vary from the estimated dates.

  13. Contact Information

    Encroachment Permit Office | Land Use Division | Humboldt County Department of Public Works | 3033 "H" Street | Room 17 | Eureka | CA | 95501 | TEL: 707.445.7205 | FAX: 707.445.7388 | EMAIL: PublicWorksPermits@co.humboldt.ca.us

  14. Leave This Blank:

  15. This field is not part of the form submission.