TOWN OF MENASHA Permit No. _______________

EXCAVATION/CONSTRUCTION      Receipt No.________

PERMIT                                             Date ___________

                                                                                                                                            PERMIT FEES

                                                                                                                        ___Construction         $25.00

Permit application for excavations, alterations or                                    ___Utility Service       $25.00

obstructions within Town of Menasha right-of-ways.                           ___Utility Mainline    $75.00

                                                                                                                          ___Escrow             $2,000.00

Application is hereby made for a permit for excavations, alterations or obstructions within Town of Menasha right-of-way.

NAME _________________________________________________PHONE_________________________

ADDRESS____________________________________________________________________________

_____________________________________________________________________________________

TYPE OF UTILITY INSTALLATION ______________________________________________________

LOCATION ___________________________________________________________________________

Applicant must provide:

¤ - Plan of Proposed Work (Must Accompany Application)

¤ - Indemnity Bond Filed With Clerk's Office

¤ - Proof of Liability Insurance

UTILITY LOCATION IS:

_____ To Cross Right-of-Way          _____ Parallel to Right-of-Way

_____ Overhead                                   _____ Underground

PROPOSED METHOD OF INSTALLATION:

_____ Tunnel            _____ Suspend on Poles         _____ Cased

_____ Jack & Bore    _____ Suspend on Towers      _____ Trench

_____ Open Cut        _____ Plow                                 _____ Other

ESTIMATED START DATE ________________ ESTIMATED RESTORATION DATE _________________

The applicant understands and agrees that the permitted work shall comply with all permit provisions and conditions listed on the reverse side hereof, special provisions as listed below or attached hereto, and any plans, details or notes attached hereto and made a part thereof. The applicant shall notify the Town of Menasha Street Superintendent 48 hours prior to the start of excavation (720-7110). Failure to comply with any regulations and/or conditions in this permit will make the permit null and void. Violations are subject to penalty under Town Ordinance Chapter Public Works 15.03(9).

BY _____________________________________TITLE___________________________________________

(Signature of Authorized Utility Representative)

                                                                                      DATE __________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PERMIT APPROVAL BY PERMITTING AUTHORITY

The foregoing applications is hereby approved and permit issued by the Town of Menasha Street Superintendent, subject to full compliance by the applicant with all provisions and conditions stated herein and all attachments hereto.

BY _____________________________________ TITLE __________________________________

(Signature of Authorized Representative)

                                                                                               DATE___________________________________

 

PERMIT PROVISIONS AND CONDITIONS OF ISSUANCE

Pursuant to Wisconsin Statutes, this permit is granted to allow performance of the specific work described herein. The following standard provisions and any included special provisions shall govern:

The Applicant agrees to indemnify and hold harmless the Permitting Authority, its employees and it agents, from any cost, claim, suit, liability and/or award which might come, be brought, or be assessed, because of the issuance or exercise of this permit, or because of any adverse effect upon any person or property which is attributed to the partially or entirely completed works of the Applicant. Accomplishment of the permitted work, or any part thereof, by or on behalf of the Applicant shall bind such Applicant to abide by this permit and all its conditions and provisions.

The permitted facilities shall, if necessary, be altered at the expense of the Applicant to permit alteration, improvement, or maintenance of the highway as may hereafter be ordered. The entire cost of constructing and maintaining the permitted facilities shall be the obligation of the Applicant unless a contract for such costs has been executed.

No open cutting for a crossing will be allowed where the pavement is too narrow to maintain one-way traffic at all times, unless the Permitting Authority has granted permission for a detour. Wherever the pavement is opened, the soil shall be hauled away and the trench shall be backfilled with sand or gravel and compacted in layers. The pavement removed for a road crossing shall be replaced as per the Permitting Authority specifications.

When one-way traffic or a detour is used, the Applicant shall provide ALL NECESSARY SIGNS, FLAGMEN AND LIGHTS required according to the "Manual on Uniform Traffic Control Devices." When a detour is allowed, local newspapers shall be notified by the Applicant in advance of the work being started.

All disturbed areas shall be returned to their original condition or better, subject to the satisfaction of the Permitting Authority or its representative. Access to all private drives and public street intersections shall be maintained, and all disturbed areas completely restored.

Any trenching, tunneling or excavating shall be performed in accordance with the requirements of OSHA and the Wisconsin Department of Industry, Labor and Human Relations, and any applicable local regulations.

A copy of this approval, along with any plans and special provisions, shall be available on the job site.

Upon completion of the work the Applicant shall file a written notice with the Permitting Authority.

 

The approval of the permit has been approved with the above eight provisions as well as the four additional provisions located below and the conditions checked below. Failure to comply with any provision or condition set forth in this permit will make this permit null and void. Violations are subject to penalty under Town Ordinance, Chapter "Public Works" 15.03 (9).

The utility or contractors shall notify the Town of Menasha Street Superintendent forty-eight (48) hours prior to the start of excavation and shall be inspected upon completion of the work. Telephone number: 920-720-7110.

The excavation permit holder shall be responsible for maintaining any settlement that occurs in the trench for a period of one (1) year after completion of excavation.

The utility or contractor shall be responsible for any or all road construction warning signs and traffic control, including flag persons, as deemed necessary and in accordance to the Manual of Uniform Traffic Control Devices; prior to, during and after commencement of street work.

All restoration of the excavated area, including permanent pavements, shoulders, ditches, etc., shall be completed within 30 days or as practical to the satisfaction of the Street Superintendent, and as directed by the Street Superintendent in accordance with the Town of Menashas specifications.

Open cutting will not be allowed under roadways or driveways. Backfill in trenches or excavated areas, outside of the roadway, can be backfilled with excavated materials and shall be compacted in layers not to exceed nine inches (9").

Open cutting shall be allowed. All trenches or excavations in the roadway shall require a cold mix patch where either hot mix, concrete or chip seal surfaces are existing. The cold patch material shall be placed following backfilling, a minimum of 3" in depth. Trenches or excavations in gravel roadways, after proper compacting, gravel will be leveled at the proper grade of the roadway.

All trenches in the roadway or proposed roadways shall be backfilled with a granular material and mechanically compacted in layers not to exceed nine inches (9").

The Utility contractor or Excavation Permit holder shall notify the Town of Menasha Street Department, Police Department and Fire Department 48 hours prior to any town road closings. The telephone numbers for the respective departments are as follows:

Street Department Phone: 920-720-7110 Fax: 920-720-7113

Police Department Phone: 920-720-7109

Fire Department Phone: 920-729-0931

All notifications of others are likewise a responsibility of the Excavation Permit holder.

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