Application And Permit To Work Form
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1APPLICATION & PERMIT TO WORK WITHIN
WASHINGTON COUNTY TRUNK HIGHWAY RIGHT‐OF‐WAY
Permit Fee ‐ $50
APPLICANT INFORMATION
THIS SECTION IS TO BE COMPLETED BY
Name: _____________________________________________________
THE HIGHWAY DEPARTMENT
PERMIT NUMBER:
Mailing Address: _____________________________________________
_______________________
City: __________________________ State: _____ Zip: ____________
Phone: ( ) ______________________________________________
*Select preferred method of contact upon
Fax: ( ) _________________________________________________
approval or denial (check one)
Email: _____________________________________________________
⃝ Mail ⃝ Fax ⃝ Email
PROJECT LOCATION AND DETAILS
County Trunk Highway (and address if applicable): _________________________________________________________________
Side of County Trunk Highway ⃝ North ⃝ South ⃝ East ⃝ West
_________________ feet ⃝ North ⃝ South ⃝ East ⃝ West of intersec on with _________________________________
Municipality: ⃝ Town ⃝ Village ⃝ City of _______________________________ Parcel ID#: ________________________
Es mated Start Date: ___________________ Es mated Comple on and Restora on Date: ___________________
Describe Proposed Work in Right‐of‐Way (Include a plan or sketch describing proposed work with this applica on):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
The following general requirements shall be adhered to during the exercise of this permit:
The applicant shall restore the highway right‐of‐way to the sa sfac on of the Highway Commissioner as soon as possible in order
to avoid a hazard to the traveling public and erosion of exposed soils.
All work within the right‐of‐way shall be performed in such a manner so as not to interfere with traffic on the adjoining roadway.
Dirt or debris deposited on highway pavement shall be removed immediately so as to not interfere with traffic.
The applicant agrees to hold harmless and indemnify Washington County, its officers, agents and employees against any loss or
damage for any personal injury or property damage sustained by reason of the exercise of this permit.
The terms and condi ons contained herein are agreed to by the applicant.
_________________________________________________
________________
Signature of Applicant
Date
THIS SECTION IS TO BE COMPLETED BY THE HIGHWAY DEPARTMENT
Permit Applica on Approved / Denied — ⃝ Approved
⃝ Denied
If approved, expira on date of permit: ______________
Special Provisions: __________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________
_________________________________
________________
Signature of Authorized Representa ve
Title
Date
Washington County Highway Department — Highway Commissioner: Sco 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
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