Shared Driveway Permit Application

Bloom Township, Fairfield County, Ohio

Please note: fill in your details on screen, then print and sign in ink. Signatures must be original — not faxed, copied, or electronic. Make checks or money orders payable to Bloom Township.

First property owner

Property owner name (required)

Address

Phone

Second property owner

Property owner name (required)

Address

Phone

Reason for request

Are there safety reasons for the shared driveway request? If yes, what are they?

Attach to this application:

A scaled site plan showing the proposed drives and any structures on either property.
Fee of $100.00 payable to Bloom Township ($50.00 per applicant).

Signatures required (sign in ink after printing)

Property #1 owner

Date

Property #2 owner

Date

For office use only

Engineer’s Office representative for a county road, or Township representative for a township road, stating he/she agrees this should be approved for sight distance and/or other safety reasons:

Engineer’s Office / Township representative

Date

Road Superintendent’s culvert instructions

Road Superintendent

Date

Zoning Administrator’s comments

Anne Cyphert, Board / Zoning Administrator

Date