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OPENING / FLUSHING PERMIT FOR HYDRANTS & VALVES CITY OF MIDDLETON - WATER UTILITY 7426 HUBBARD AVE, MIDDLETON, WI 53562 (608) 821-8370 ● FAX (608) 827-1080 [EMAIL REDACTED] This form must be completed and returned to the Middleton Utility office 24 hours prior to opening or flushing any hydrant or valves. The only exception is an emergency situation. If flushing is not completed on the date stated, the contractor must reapply. APPLICANT (NAME OF BUSINESS) BILLING ADDRESS PHONE EMAIL TYPE TO BE FLUSHED (Check one.) HYDRANT VALVE NUMBER OF HYDRANT(S) / VALVE(S) TO BE FLUSHED SIZE OF VALVE / MAIN TO BE FLUSHED LOCATION OF HYDRANT(S) / VALVE(S) REASON FOR OPENING / FLUSHING DATE TO BE OPENED / FLUSHED TIME AUTHORIZED SIGNATURE DATE Unauthorized removal of water from the City of Middleton Utility District distribution system is a violation of subsection 9.02(16) of the Utility Ordinance and subsection 941.36 of the Wisconsin Statutes. The City of Middleton will take appropriate legal action to ensure compliance with these regulations. Permits will be issued at the discretion of the City of Middleton Utility. OFFICE USE ONLY DATE ACTUAL TIME FLUSHED: HOURS MINUTES ESTIMATED AMOUNT OF WATER FLUSHED gallons NAME OF PERSON FLUSHING INFORMATION RECEIVED/ENTERED BY