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APPLICATION/PERMIT TO WORK ON HIGHWAY RIGHT-OF-WAY <br /> Wisconsin Department of Transportation(WisDOT) <br /> DT1812 6/2006 s.86.07(2),86.16 and other applicable Wis.Stats. <br /> To each copy of the application, attach one copy of the sketch showing location. <br /> Location Description-quarter section,section,township, range,etc. Proposed Work Location <br /> NW 1/4 of the NW 1/4, section 8, T5N R1OE ® Town El Village El City <br /> of Rutland <br /> County <br /> Dane <br /> Applicant Name and Address Starting Date Highway <br /> Leslie Swanson <br /> 1022 S. Perry Pkwy. ® STH 138 <br /> Oregon, WI 53575 <br /> Completion Date ❑ USH <br /> ❑ Interstate <br /> Type of Work Proposed <br /> Driveway <br /> An 18" minimum culvert is required with two endwalls. <br /> It is understood and agreed that approval is subject to the applicant's full compliance with the pertinent Statutes, as well as <br /> any codes, rules, regulations, and permit requirements of other jurisdictional agencies. The applicant shall also comply <br /> with all permit provisions, superimposed notes, and detail drawings, which may be added by WisDOT. Any alteration of <br /> this form by the applicant is prohibited and may be cause to revoke this permit. <br /> X <br /> (Main Contractor, If applicable) (Applicant or Authorized Representative) (Date) <br /> (If Computer-filled,Brush Script Font) <br /> (Contractor Representative/Title) (Printed Name) (Title) <br /> (Office Telephone Number) (Cellular Telephone Number) (Telephone Number) <br /> *If the work described is not completed by the"Completion Date"specified,this permit is null and void and the work shall not be <br /> completed unless authorized through a subsequent permit or an approved time extension. <br /> Transportation Regional Location and Telephone Number Date Application Received by WisDOT <br /> Madison <br /> El The applicant shall contact the Transportation Regional Office at the Telephone Special Telephone Number <br /> Number given at right NOT LESS THAN 3 WORKING DAYS prior to the start of the <br /> permitted work to arrange for a Regional Representative to locate and mark the <br /> existing traffic signal lines. No work under this permit shall be accomplished prior <br /> to the Regional Representative's arrival. <br /> Wisconsin Department of Transportation Permit Approval <br /> ❑ This permit is issued in conjunction with: <br /> ❑ This permit voids and supersedes: Permit# Issued <br /> Permit Number Iss7 n.2 ate O Q X <br /> 13-20-08 / o <br /> (WisDOT Authorized Representative) <br /> (If Computer-filled, Brush Script Font) <br /> THIS PERMIT IS REVOCABLE <br />