Attachment 4- 01 50 02 - WDOT Application-Permit To Work On Highway Right-Of-Way.pdf

APPLICATION/PERMIT TO WORK ON HIGHWAY RIGHT-OF-WAY

Wisconsin Department of Transportation (WisDOT) DT1812 1/2016 s. 86.07(2), 86.16 and other applicable Wis. Stats.

1. Applicant’s Name, Address, City, State and ZIP Code

Contractor to Complete

2. Work Start Date

4. Location Description (¼ section, section, town, range; provide plat and location maps)

West end of the Sturgeon Slough Hiking Trail parking and access off of USH 18 west of Prairie du Chien. Town of Bridgeport NWNE3507N07W 3. Work Finish Date

5. Is the work area near a survey monument? (If yes, call 866-568-2852 or email geodetic@dot.wi.gov.) Yes No

6. Work Location (List all that apply)

Town: Bridgeport

Village:

City:

County: Crawford

7. Highway (List all that apply)

WIS

US 18

Interstate ______

8. Trans 401 project designation? (Provide a formal erosion control plan for all Major projects. See provision #13.) Major Minor

9. Are any environmental approvals, certifications or permits required from other regulatory agencies? (If yes, provide a copy of each item. If no, provide proof of other agency coordination as needed. For additional information, go to environmental coordination.)

Yes No

10. Work Type (Check all that apply)

Access management Crash investigation/cleanup Drainage: Culverts/tiles Drainage: Grading/riprap Drainage: Storm Sewer Environmental assessment Harvesting nature products Hazmat: Cleanup/remediation Hazmat: Monitoring wells Invasive species assessment Landscaping Soil borings Surveying

11. Vegetation Management (Check all that apply)

Mow Remove Prune Cut and/or trim Plant Chemically treat13

12. Work Zone Description (Check all that apply)

Not applicable Full road closure: detour Full road closure: temporary Lane closure: without flagging Lane closure: with flagging Lane encroachment (2 feet or less) Intersection/roundabout Shoulder/parking lane closure

Freeway/expressway location Off shoulder: < 30' off white line Off shoulder: ≥ 30' off white line Near right-of-way line or fence

Non–Freeway/expressway location Off shoulder: < 15' off white line Off shoulder: ≥ 15' off white line Back of curb: < 2' behind Back of curb: ≥ 2' behind

13. Provide detailed description of how work will be accomplished. Use page 2 or additional pages if needed. Provide work plans, drawings and specifications as needed. For chemical treatment, answer questions on page 2.

The Contractor will be placing a field office in the western portion of the Sturgeon Slough Hiking Trail parking lot west of Prairie du Chien oalong USH 18. The field office is for a dredging and habitat improvement project over a three year period. The field office is to be located on the west side of the parking area. Access to the Sturgeon Slough Hiking Trail and limited parking are to be maintained.

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 other jurisdictional agencies’ permit requirements. Applicant shall comply with all 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 convey any land right, right in land, nor easement in WisDOT right-of-way. It is not assignable or transferrable. All costs associated with this permit are the permittee’s responsibility unless otherwise noted.

X (Main Contractor Company Name, If applicable) (Applicant or Authorized Representative Signature)

(If Computer-filled, Brush Script Font) (Date)

(Contractor Representative/Title) (Area Code/Phone No. – Office) (Printed Name) (Title)

(Area Code/Phone No. – Cell) (Email Address) (Area Code/Phone No.) (Email Address)

Includes permanent restoration. If the permitted work has not started by the “Work Finish Date”, this permit is null and void. If the permitted work has started, but has not been completed by the “Work Finish Date”, the work shall not be completed unless authorized through an approved written time extension or a subsequent permit. ANY PERMIT ISSUED IS REVOCABLE.

For Official Wisconsin DOT Use Only – Do Not Write Below

PERMITTEE SHALL NOTIFY THE WISDOT REPRESENTATIVE

LISTED BELOW 3 DAYS BEFORE STARTING ANY WORK:

Region contact, title, office address, area code/phone no., and email address

Eric Glindinning Area Maintenance Coordinator Wisconsin DOT Southwest Region - La Crosse Office 3550 Mormon Coulee Road La Crosse, WI 54601 eric.glindinning@dot.wi.gov

See Supplemental Permit Provisions (Page 4) Special Permit Provisions Also Included Lane Closure System notification required Insurance or performance bond required Other regulatory agency permits not required State highway traffic detour permit required Permit issued in conjunction with:

Permit voids and supersedes permit(s):

# , Issued

Date Application Received

6-26-20 Date Application Complete

Permit Issuance Date

Permit Expiration Date

Permit Extension Date

Permit Number

(WisDOT Authorized Representative Signature – If Computer-filled, Brush Script Font)

DT1812, Application/Permit to Work on Highway Right-of-Way, Page 2 of 4

Use this section to provide information on chemical treatment (question #11):

(a) Chemical(s) to be used and EPA Registration Number(s)?

(Example: Garlon 4 Ultra, EPA REG. NO. 62719-527)

(b) Type of application(s)? (Example: Stump treatment, broadcast, etc.)

(c) Applicator name(s) and Wisconsin certification number(s)?

(Example: Bill Smith, 146886-CA. Personnel must be licensed as commercial applicators in category 6.0, Right-of-Way, to legally apply herbicides on roadsides.)

(d) How will property owners bordering the affected highway ROW be notified prior to spraying?

(Examples: In-person, doorknob cards, letters, phone calls, etc.)

(e) Will spraying occur near wetlands? (If yes, see question #9)

(f) Provide name(s) and cell number(s) for the supervisor or lead worker of each crew:

Use this section to provide information that does not fit on front page or #11(a)-(f) on left:

INDEMNIFICATION

The Applicant shall save and hold the State, its officers, employees, agents, and all private and governmental contractors and subcontractors with the State under Chapter 84 Wisconsin Statutes, harmless from actions of any nature whatsoever (including any by Applicant itself) which arise out of, or are connected with, or are claimed to arise out of or be connected with any of the work done by the Applicant, or the construction or maintenance of facilities by the Applicant, pursuant to this permit or any other permit issued by the State for location of property, lines or facilities on highway right-of-way, (1) while the Applicant is performing its work, or (2) while any of the Applicant's property, equipment, or personnel, are in or about such place or the vicinity thereof, or (3) while any property constructed, placed or operated by or on behalf of Applicant remains on the State's property or right-of-way pursuant to this permit or any other permit issued by the State for location of property, lines or facilities on highway right-of-way; including without limiting the generality of the foregoing, all liability, damages, loss, expense, claims, demands and actions on account of personal injury, death or property loss to the State, its officers, employees, agents, contractors, subcontractors or frequenters; to the Applicant, its employees, agents, contractors, subcontractors, or frequenters; or to any other persons, whether based upon, or claimed to be based upon, statutory (including, without limiting the generality of the foregoing, worker's compensation), contractual, tort, or whether or not caused or claimed to have been caused by active or inactive negligence or other breach of duty by the State, its officers, employees, agents, contractors, subcontractors or frequenters;

Applicant, its employees, agents, contractors, subcontractors or frequenters; or any other person. Without limiting the generality of the foregoing, the liability, damage, loss, expense, claims, demands and actions indemnified against shall include all liability, damage, loss, expense, claims, demands and actions for damage to any property, lines or facilities placed by or on behalf of the Applicant pursuant to this permit or any other permit issued by the State for location of property, lines or facilities on highway right-of-way in the past or present, or that are located on any highway or State property or right-of-way with or without a permit issued by the State, for any loss of data, information, or material; for trademark, copyright or patent infringement; for unfair competition or infringement of personal or property rights of any kind whatever. The Applicant shall at its own expense investigate all such claims and demands, attend to their settlement or other disposition, defend all actions based thereon and pay all charges of attorneys and all other costs and expenses of any kind arising from any such liability, damage, loss, claims, demands and actions.

Any transfer, whether voluntary or involuntary, of ownership or control of any property constructed, placed or operated by or on behalf of the Applicant that remains on the State's property or right-of-way pursuant to this permit shall not release Applicant from any of the indemnification requirements of this permit, unless the State is notified of such transfer in writing. Any acceptance by any other person or entity, whether voluntary or involuntary, of ownership or control of any property constructed, placed or operated by or on behalf of the Applicant that remains on the State's property or right-of-way pursuant to this permit, shall include acceptance of all of the indemnification requirements of this permit by the other person or entity receiving ownership or control.

Notwithstanding the foregoing, a private contractor or subcontractor with the State under Chapter 84 Wisconsin Statutes, that fails to comply with sections 66.0831 and 182.0175 Wisconsin Statutes (2013-2014), remains subject to the payment to the Applicant of the actual cost of repair of intentional or negligent damage by the contractor or subcontractor to any property, lines or facilities placed by or on behalf of the Applicant pursuant to this permit or any other permit issued by the State for location of property, lines or facilities on highway right-of-way, and remains subject to payment to the Applicant for losses due to personal injury or death resulting from negligence by the contractor or subcontractor.

Notwithstanding the foregoing, if the State, or its officers, employees and agents, fail to comply with sections 66.0831 and 182.0175 Wisconsin Statutes (2013-2014), the State or its officers, employees and agents, remain subject to the payment to the Applicant of the actual cost of repair of willful and intentional damage by the State, or its officers, employees and agents, to any property, lines or facilities placed by or on behalf of the Applicant pursuant to this permit or any other permit issued by the State for location of property, lines or facilities on highway right-of-way, and remain subject to payment to the Applicant for losses due to personal injury or death resulting from negligence by the State, its officers, employees and agents.

No indemnification of private contractors or subcontractors with the State under Chapter 84 Wisconsin Statutes, shall apply in the event of willful and intentional damage by such private contractors or subcontractors to the property, lines and facilities of the Applicant located on the highway right-of-way pursuant to this permit or any other permit issued by the State for the location of property, lines or facilities on highway right-of-way.

GENERAL PERMIT PROVISIONS AND CONDITIONS OF APPROVAL (#1-28)

DT1812, Application/Permit to Work on Highway Right-of-Way, Page 3 of 4

Pursuant to Wisconsin Statutes and once approved by WisDOT, this permit allows performance of the specific work described over which WisDOT has permit authority. The permittee shall abide by these general provisions, and any supplemental and/or special provisions. (ROW = right-of-way)

1. Warning signs, devices and methods shall be in place and fully functional prior to the start of any permitted work within highway ROW, and shall protect the public until all permitted work is complete. Warning signs and devices shall conform to the appropriate sizes, designs and configurations specified within the Wisconsin Manual of Uniform Traffic Control Devices, current edition.

Provide and maintain the quantity of signs and devices therein described, and supplement those with additional signs, devices and flaggers as necessary to functionally protect people and property from injury or damage at all times and under all conditions, including changed or changing conditions. All personnel shall wear retro-reflective safety vests while working within the highway ROW.

2. Secure the work site and associated traffic control zone against any hazard to the public, both when the site is attended and is unattended during off-hours, holidays, and nighttime hours. This includes vehicles, equipment and materials. Any violation of this permit, particularly any failure to maintain safe work site and traffic control zone, will require immediately cure by the permittee, and may result in WisDOT stopping further work, removal of permittee from the highway ROW, and/or permit revocation.

3. Coordinate the permitted work and in no case interfere with any ongoing highway improvement project.

4. Keep a complete copy of the permit (which may be electronic) at the job site at all times the permitted work is ongoing along with a project manager or supervisor familiar with the permit and all of its details and requirements. Failure to comply with any part of this permit is the permittee’s responsibility.

5. Determine the location of, and protect or cause to protect from any damage, any existing facilities in the area affected by the permitted work. All notifications to other facility owners are the permittee’s responsibility.

6. Perform all permitted work without obstructing or closing any part of any traffic lane or fully closing any road unless specifically authorized by WisDOT.

7. Alter the permitted facilities as may be ordered by WisDOT to facilitate highway improvement, alteration, safety control, or maintenance. Accept all costs of constructing, maintaining, altering, temporarily moving or relocating the permitted facilities.

8. The permit authorizes only the described work of and for the permittee indicated on this permit. It does not grant authority for the work of any other, either by present or future installation.

9. Any disturbance to, operation within, or use of a highway median is expressly prohibited, unless specifically authorized by WisDOT. The use of interstate or freeway median crossovers for any reason is prohibited and subject to law enforcement citation.

10. Construction methods and restorations shall be in accordance with applicable parts of WisDOT’s Standard Specifications for Highway and Structure Construction, current edition.

11. Comply with all applicable regulations and codes, including, but not limited to, the U.S. Department of Labor, Occupational Safety and Health Administration, 29 CFR Part 1926 for construction safety precautions and operations.

12. Do not open at any time any greater length of trench than is necessary to maintain essential progress of the work.

13. Implement erosion control best management practices (BMPs) prior to and at all times during work operations. Provide and maintain erosion control BMPS to protect all restored areas upon completion of the permitted work until the replacement vegetation achieves sustained growth. Trans 401 designations for major and minor projects in this permit use the same meanings as utility projects. If a project is not “minor”, then it is “major”.

14. Derive no direct access to install, maintain or repair the permitted facility from the freeway travel lane or shoulder or any interchange ramp, unless specifically authorized by WisDOT or if needed due to an emergency. In the latter case, immediately contact the Wisconsin State Patrol and WisDOT Region Office as indicated on this permit.

15. Install the facility in the specified permit location. Move any part of the facility found to be otherwise located to the correct location upon WisDOT order. Any facility part located other than as specified in this permit is at permittee’s sole risk. Accordingly, if the same is undetected or is suffered to remain in variance to the permit, the permittee shall hold the State, its employees, agents and officers harmless and free of any cost, claim or liability associated with any accidental damage to such facility that may result from a highway construction, maintenance, traffic control, or ROW management project or function.

16. Promptly restore all highway facilities disturbed by the permitted work or associated operation. This includes natural highway facilities, including but not limited to living snow fence, headlamp screens, and other such highway safety features. WisDOT may issue a notice setting a specific time by which the restoration must be complete if restoration is not done voluntarily without delay. If the permittee fails to satisfactorily complete the restoration within the time established, WisDOT shall arrange for the restoration to be completed and bill the permittee accordingly. The permittee shall pay for all restoration costs.

17. Collect any brush, trash or waste materials resulting from the permitted work, and dispose of said materials off the ROW in accordance with applicable solid waste disposal regulations.

18. Send notice within 10 calendar days via regular mail or email to the authorized WisDOT representative who approved the permit upon completion of the work and restoration.

19. Smooth and finished slopes shall be constructed at any location where any regraded portion of the highway ROW meets the lands of adjacent property owners.

20. Backfill any excavation permitted within the highway pavement limits or shoulder areas with suitable granular material, placed in lifts or layers 12 inches or less each in depth, and mechanically compact to meet the appropriate density as specified in WisDOT’s Standard Specifications for Highway and Structure Construction, current edition. Do not use water jetting to accomplish mechanical compaction. Repair to WisDOT’s satisfaction any subsequent heavings, settlings, or other faultings attributable to the permitted work. Use temporary sheeting, shoring and/or trench boxes as needed to prevent trench/tunnel cave-ins.

21. Restore in-kind any curb, gutter, sidewalk, driveway, gravel base, ballast, shoulder material, or other highway ROW element/facility disturbed under this permit to the qualities, grades, compactions and conditions specified in WisDOT’s Standard Specifications for Highway and Structure Construction, current edition.

22. Restore any turfed ROW area disturbed under this permit with fine-graded topsoil having a depth of not less than 4 inches, and reseeded to perennial grass or sodded to WisDOT’s satisfaction.

23. Adjust manhole covers, shut-off and regulator valves, and like facilities to the level of the immediately adjacent grades.

24. Cure faults related to work or facilities under this permit that, in WisDOT’s opinion, obstruct highway drainage or in any other manner adversely affect highway maintenance or operation, and restore the ROW as directed by and to WisDOT’s satisfaction.

25. Keep all vehicles/equipment/materials outside the ROW fence including all bore pits of any bored or augered installations under a freeway. Do not keep vehicles/equipment/materials between any freeway travel lane and a bore pit if WisDOT authorizes the pit location within the freeway ROW. Locate all bore pits outside the clear zone and as close to the ROW fence as possible.

26. Do not keep vehicles/equipment/materials related to this permit within the non-freeway ROW limits except as are actively engaged in the work operation.

27. Be aware that future highway improvements may require the adjustment of part or all of the permitted facility, at permittee’s cost, to conform to WisDOT’s Utility Accommodation Policy.

DT1812, Application/Permit to Work on Highway Right-of-Way, Page 4 of 4

28. Comply with appropriate laws, rules, policies, etc. when within tribal or federal lands. Provide documentation as needed when on WisDOT ROW to prove compliance or coordination with the following agencies:

SUPPLEMENTAL PERMIT PROVISIONS (#29- )

The permittee shall abide by the following checked provisions:

TREE & VEGETATION MANAGEMENT

29. Plant trees/vegetation only in such locations and in such species as indicated on the plans included and approved with this permit, or as WisDOT specifies in the field.

30. Maintain all plantings according to the attached special permit provisions.

31. Do not place any sign or marker identifying the plantings within the highway ROW limits.

32. WisDOT accepts no responsibility for loss that may occur to the plantings. Be fully aware that the plantings are subject to:

33. Do not cut, trim or damage trees/vegetation to facilitate the installation or maintenance of the permitted facility except as authorized by the owner of such tree/vegetation. See Wis. Stat.

ss. 86.03(2), (4), 86.16(3), and 182.017(5).

34. Do not cut or prune oak trees between April 15 and October 15 to prevent Oak Wilt Disease from spreading unless a thick coat of asphalt base tree paint is applied immediately after any cut, pruning wound, or abrasion made between those dates. Cleanly cut the exposed ends of any roots encountered during grading or trenching with suitable pruning tools immediately after exposure.

Adhere to any applicable laws, including local ordinances if they are stricter than WisDOT specifications.

35. Remove all stumps, branches, logs, and other debris resulting from the cutting and trimming operations and dispose of such materials off the ROW. Tree disposal may also occur by giving them to the adjacent property owner(s) at a storage location approved by the owner(s). Comply with applicable laws that regulate the sale, transport, or pruning/cutting of trees.

36. Cut trees flush with the ground. Any remaining stumps shall not interfere with mowing operations.

37. Cut trees may be chipped and used for mulch on the ROW in a layer not exceeding three inches.

38. Trim only the trees/vegetation necessary to provide safe clearances or by special provisions. Do not damage non-target trees/vegetation. Do not clear cut trees/vegetation.

39. Survey the trees/vegetation to be removed and inspect jointly with a WisDOT representative prior to starting any work on the highway ROW.

40. Treat all deciduous tree stumps with a herbicide approved for this use. Do not treat evergreen tree stumps.

41. Follow the conditions specified in WisDOT’s “Vegetation Alteration Decision” for vegetation removed or trimmed pursuant to Wis. Stat. s. 84.305.

RAILROAD CROSSING WORK

42. Complete a permit/application form to detour state highway traffic (DT1479). This DT1812 permit shall only be in effect if WisDOT approves the matching DT1479 permit.

43. Comply with the attached “Special Provisions for Railroad Crossing Work.”

WORK RESTRICTIONS

44. Daily, holiday and/or seasonal work restrictions apply to the permitted work as detailed on page . Review the restrictions with the WisDOT Region Office(s) identified on this permit.

MISCELLANEOUS

45. Contact the WisDOT Region Office(s) identified on this permit to arrange for a Region representative to inspect the work site.

Perform no work under this permit prior to his/her arrival.

46. Contact the WisDOT Region Office(s) identified on this permit prior to completing the permitted work to arrange for a Region representative to inspect the work before the permittee’s employees or contractor leaves the site.

47. Call the State Traffic Operations Center (STOC) / -on a weekly basis or as otherwise determined by the STOC before working on any interstate or other major freeway. The STOC may place restrictions on work times and lane/shoulder closures based upon various special events, oversize freight movements, or daily peak travel times.

48. Construction by open-trench methods is authorized only if the permitted installation can be accomplished in advance of the highway paving. Bore or dry auger the permitted facility if this cannot be accomplished.

49. At any location where open-trench installation across highway pavement is authorized, saw-cut the surface full depth to enable it to be restored with smooth joints. Restore concrete pavement to the nearest joint.

50. Backfill all excavations according to the attached detail.

51. Blasting within the highway ROW is authorized with this permit.

52.

Wisconsin Historical Society to avoid/mitigate any potential cultural resource (archeological, historical, burial site, etc.)

impacts per Wis. Stat. s. 44.40.

Department of Natural Resources to avoid/mitigate any potential storm water runoff, site erosion, wetland, waterway and endangered/threatened species impacts.

Thinning and/or mortality Normal hazards due to maintenance operations, snow control, and public utility installation or alteration Trimming or removal, if or when the plantings cause restrictions to sight distance or hazardous snow/ice conditions on the highway

Destruction, if highway reconstruction is done Partial or complete abandonment or obliteration, or return to private ownership, if future changes in highway location are made