DCPZP-2017-00077 - Laserfiche WebLink

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APPLICATION/PERMIT TO WORK ON HIGHWAY RIGHT-OF-WAY Wisconsin Department of Transportation(WisDOT) DT1812 5/2012 s.86.07(2),86.16 and other applicable Wis.Stats. 1.Applicant Name and Address 2.Work Start Date 3.Work Finish Date" 4.Highway(Check all that apply) Joseph Eugster March 2017 5/1/2017 ® WIS 138 3865 STH 138 5.Work Location(CheckAist all that apply) ❑ US Stoughton,WI 53589 ® Town ❑ Village ❑ City of: Rutland ❑ Interstate County: Dane ❑ 6.Is the work area near a survey 7.Trans 401 project designation? 8.Location Description(Town,range,section,'/,sect;provide plat map or location monument? (If yes,email ❑ Yes (For all Major projects,provide a ® Minor sketch) neodetloOdotwi.gov or ® No formal erosion control plan with ❑ Maj call 866-568-2852.) this application.) or T5N, R10E,Section 10, NW 1/4 of the SW 1/4 9.Are any environmental permits,certifications or approvals required from other regulatory agencies,including tribal governments? (If yes,provide a copy of each ❑ Yes item. If no,proof of agency coordination may still be required with this application. ® No Click on environmental coordination for more information.) 10.Work Type(Check all that apply) 12.Work Zone Description(Check all that apply) 13.Provide Detailed Description of How Work Will Be Accomplished(Use additional pages if needed. Provide work plans and specifications as needed.) ❑ Access management ❑ Not applicable Driveway is being reshaped for a new residence. ❑ Crash investigation/cleanup ❑ Full road closure:detour** ❑ Drainage:Culverts/tiles ❑ Full road closure:temporary ❑ Drainage:Grading/riprap ❑ Lane closure:without flagging ❑ Drainage:Storm Sewer ❑ Lane closure:with flagging ❑ Environmental assessment ❑ Lane encroachment(2 feet or less) ❑ Harvesting nature products ❑ Intersection/roundabout ❑ Hazmat:Cleanup/remediation ❑ Shoulder/parking lane closure ❑ Hazmat:Monitoring wells Freeway/expressway location ❑ Invasive species assessment ❑ Off shoulder:<30'off white line ❑ Landscaping ❑ Off shoulder:>-30'off white line ❑ Soil borings ❑ Near right-of-way line or fence ❑ Surveying Non-Freeway/expressway location ❑ Other: ® Off shoulder.<15'off white line 11.Vegetation Management(Check all that apply) ❑ Off shoulder:?15'off white line ❑ Mow ❑ Chemically treat ❑ Back of curb:<2'behind ❑ Prune ❑ Cut and/or trim ❑ Back of curb:_'2'behind ❑ Plant ❑ Remove „locos'** It is understood and agreed that approval is subject to the applicant's full compliance with the pertinent Statutes,as well as any codes,rules,regulations,and permit requirements of other jurisdictional agencies.The applicant shall also comply with all kti„. permit provisions,superimposed notes,and detail drawings that WisDOT may add.Any alteration of this form by the applicant is prohibited and may be cause to revoke this permit When approved,the permit does not transfer any land;nor give,grant or or convey any land right,right in land,nor easement in WisDOT right-of-way. It is not assignable or transferrable. O t\ l C -isi.C"\C)V\ X P frfri Sass' 03/08/2017 (Main Contractor Company Name,If applicable) (Applicant or Authorized Representative) (Date) Cw .0 6 0 P~ (-)6k5 1 cSn-7 (If Computer-filled,Brush Script Font) Joeseph Eugster (Contractor Representative/Title) (Office Telephone Number) (Printed Name) (Title) 608 279-3502 'farmmrkt @eugsters.com (Cell Telephone Number) (Email Address) (Telephone Number) (Email Address) *NOTE: If the work described is not completed by the"Work Finish Date"specified,this permit is null and void and the work shall not be completed unless authorized through a subsequent permit or an approved time extension.ANY PERMIT ISSUED IS REVOCABLE. For Official Wisconsin DOT Use Only-Do Not Write Below • ❑ PERMITrEE SHALL NOTIFY THE WISDOTREPRESENTATIVE ❑ See Supplemental Permit Provisions(Page 4) Date Application Received LISTED BELOW 3 DAYS BEFORE STARTING ANY WORK: ❑ Special Permit Provisions Also Included 03/08/2017 Region contact,title,office address,telephone number,and email address Date Application Complete ❑ Lane Closure System notification required Scot Hinkle ❑ Insurance or performance bond required 03/08/2017 Southwest Region-Madison Office Permit Issuance Date 2101 Wright Street ❑ Other regulatory agency permits not required 03/09/2017 Madison,WI 53704 ❑ **DT1479,"Application/Permit to Detour State Permit Expiration Date 608 246-5334 Highway Traffic"required 06/30/2017 ® This permit is issued in conjunction with:— Permit Extension Date ❑ This permit voids and supersedes permit(s): # , Issued Permit Number S'C4tt ! is ® "**'13-100224207-2017 13-3-17 (WisDOT Authorized Representative Signature—If filled via computer,Brush Script font)