Form Cu-99-1 -Application & Permit To Construct, Maintain, And Operate Utilities Within Washington County Trunk Highway Right-Of-Way printable pdf download

APPLICATION & PERMIT TO CONSTRUCT, MAINTAIN, AND OPERATE UTILITIES

WITHIN WASHINGTON COUNTY TRUNK HIGHWAY RIGHT-OF-WAY

(Form CU-99-1 Revised 1/4/16)

Permit Fee - $75

Open Cut Pavement - $200 per pavement cut, plus permit fee

Payment submitted with this application: $_______________ - OR - Annual Service Connection Permit: ⃝ Yes ⃝ No

APPLICANT INFORMATION

THIS SECTION IS TO BE COMPLETED BY THE HIGHWAY DEPARTMENT

Name: _____________________________________________________

PERMIT NUMBER:

Address: ___________________________________________________

_______________________

City: __________________________ State: _____ Zip: ____________

If ASCP - number ___ of 35 in calendar year: _______

Phone: (

) ______________________________________________

PROJECT LOCATION

Fax: (

) _________________________________________________

County Highway: __________

Email: _____________________________________________________

*Select preferred method of contact upon approval or denial (check one)

Municipality: ⃝ Town

⃝ Village

⃝ City

⃝ Mail

⃝ Fax

⃝ Email

of __________________________________

PROJECT DETAILS

Describe Type of Utility Installation: _____________________________________________________________________________

Utility Person Responsible for Construction — Name: _____________________________ — Phone: (

) __________________

Plans Prepared by — Name: _____________________________ — Phone: (

) __________________

Estimated Start Date: ___________________

Estimated Restoration Date: ___________________

(check all that apply)

⃝ To cross roadway

⃝ Overhead

⃝ Underground

⃝ Parallel to centerline of road

⃝ Tunnel

⃝ Trench

⃝ Open cut

⃝ Suspend on towers

⃝ Jack and bore

⃝ Cased

⃝ Suspend on poles

⃝ Tree cutting / removal

⃝ Bridge attachment

⃝ Water

⃝ Sanitary sewer

⃝ Telephone / communicator

⃝ Gas / electric

⃝ Chemical treatment

⃝ Other(s) ________________________________________

All department, county, utility, and contractor personnel who are out of their vehicles and within the road rights-of-way must wear

ANSI approved safety apparel meeting ANSI class 2 or 3 requirements.

The Applicant understands and agrees that the permitted work shall comply with all permit provisions and conditions of the

Washington County Utility Policy (available on-line at: ) in effect at the time of this application and

with any special provisions listed below or attached hereto, and any and all plans, details, or notes attached hereto and made a

part thereof.

___________________________________________

_________________________________

________________

Signature of Applicant / Authorized Representative

Title

Date

THIS SECTION IS TO BE COMPLETED BY THE HIGHWAY DEPARTMENT

Permit Application Approved / Denied — ⃝ Approved

⃝ Denied

If approved, expiration date of permit: ______________

Special Provisions: __________________________________________________________________________________________

__________________________________________________________________________________________________________

___________________________________________

_________________________________

________________

Signature of Authorized Representative

Title

Date

Washington County Highway Department — Highway Commissioner: Scott M. Schmidt, PE, PLS

ADDRESS: 900 Lang Street, West Bend, WI 53090-2666 ▪ PHONE: (262) 335-4435 ▪ FAX: (262) 335-4439 ▪ EMAIL: webhwy@co.washington.wi.us

Form Cu-99-1 -Application & Permit To Construct, Maintain, And Operate Utilities Within Washington County Trunk Highway Right-Of-Way

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