No Date - WC Blank Utility Permit Form
C TYPE OF WORK
o DATE STARTED
M CONTRACTOR USED
P CONTACT PERSON
A
N
Y
-
U
T
I
L
I
T
Y
L
WRIGHT COUNTY HIGHWAY DEPARTMENT
UTILITY PERMIT .
J 93-/3-.5 ]
<:' ..Y"'9 # .3 ~-
UTI LIT Y
P B R " I T
COM P LET ION
P 0 R M
DATE COMPLETED
PHONE:
The above work was completed as required by the utility
specifications.
Signed
Date
--------------------------------------------------------------------------
.--
Inspector:
C
o
U
N
T
Y
o
N
L
Y
---
o
o
o
Date:
0 ENTRANCES 0 RESTORATION (TURF)
0 SIGNS 0 GUY WIRES
0 TRAFFIC CONTROL -0 OTHER
o COMMENTS:
F
F
I
C
E
LOCATION (CL)
CULVERTS
BITUMINOUS PATCH
The above work met the requirements of the utility permit.
Signed
Date