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DOUGLAS COUNTY HIGHWAY DEPARTMENT UTILITIES PERMIT FEE The permit fee is based on the cost of the project. The following is the scale: Cost of the Project Permit Fee <$5,000 $10.00 $5,000 to $49,999 $30.00 $50,000 to $499,999 $50.00 >$500,000 $100.00 Mail The Completed Permit and Money To: Douglas County Highway Department 7417 South County Road E P.O. Box 174 Hawthorne, WI 54842 [PHONE REDACTED] phone [PHONE REDACTED] fax Print Form ---PAGE BREAK--- DOUGLAS COUNTY HIGHWAY DEPARTMENT APPLICATION / PERMIT TO CONSTRUCT, OPERATE AND MAINTAIN UTILITIES WITHIN HIGHWAY RIGHT-OF-WAY Applicant / Company: Street Address, City, State, Zip: Phone-Fax and Cell: Plans Prepared By: Preparer’s Phone: LOCATION INFORMATION: Highway(s): Town/Village/City of: ¼ of the ¼ Section, Township, Range: Annual Service Connection Permit? Utility Work Order # Fee Required? Amount $ DESCRIPTION OF PROPOSED WORK (Check and fill out all that apply) Utility Type: Electric Gas/Petroleum Communications Water Sanitary Sewer Private Line Transmission Distribution Service Facility Size/Capacity: (diameter, #fibers, psi, Kv, etc.) Orientation: Overhead Underground Parallel to Hwy Centerline Hwy Crossing Tunnel Bridge Attachment Work Type: New Construction Improve/Repair Existing Maintenance Removal Abandon in place Construction Method(s): Plow Trench Bore Suspend on Poles/Towers Open Cut Hwy Cased Tree Cutting/Removal Chemical Treatment of Trees/Brush Erosion Control Designation: Provide additional narrative if needed: Name and Phone Number of Utility Representative Responsible for Construction: Estimate Start Date: Estimated Completion/Restoration Date: The Applicant understand and agrees that the permitted work shall comply with all permit provisions and conditions of the Utility Accommodation Policy of the Douglas County Highway Department 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. By: (Signature of Applicant/ Company Authorized Representative) (Title) (Date) (Print Name) (Telephone Number) DO NOT WRITE BELOW THIS LINE PERMIT APPROVAL BY PERMITTING AUTHORITY The foregoing application is hereby approved and permit issued by the Permitting Authority subject to full compliance by the Applicant with all provisions and conditions stated in the Utility Accommodation Policy of the Douglas County Highway Department including the Indemnification as included in 96.03 of the WCHA Utility Accommodation Policy in effect on the date of this application. Supplemental Provisions Attached: Yes No By: (Authorized Representative for Douglas County) Title Date Date Revised: 5/2011 FEE RECEIVED: CHECK NUMBER: DATE ISSUED: HWY PROJECT PERMIT NUMBER: No No Minor Reset Form