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4R <br /> Circle One: New Constructio Improvement (see page 1 for explanation) Permit Reinstatement <br /> Part 2: Application for Permit: The undersigned hereby applies for a permit to construct a driveway in the <br /> Town of Vermont, Dane County,Wisconsin. <br /> The driveway will be in Section 2,3 of the Town of Vermont, <br /> Entering Town or County Road or State Highway County Road JJ <br /> Through property owned by: <br /> Name of Property Owner: es Elleson <br /> Signature: Date: 3/23/14 <br /> Mailing Address: 4 1 County Road JJ,Black Earth,WI 53515 <br /> Phone: 767-3553 Email: jim @quercus-LS.com <br /> Name of Applicant: <br /> Signature: Date: <br /> Mailing Address: <br /> Phone: Email: <br /> Contractor: <br /> A driveway construction plan and erosion control plan will be required for new driveway construction. An engineer <br /> plan may be required. <br /> Does the applicant desire to use material from the excavation of the house site to provide fill for the proposed <br /> drivewayn? Yes . If"y❑es", an excavation permit must be obtained from the Town Building Inspector. <br /> Proposed driveway length in feet: 1500 <br /> Application & Fee Received by: � � � <br /> 6.Cc Date: 3-ZS`/`T' cti Ro <br /> Driveway Construction Permit and Inspection Application <br /> Part 3: Board Approval of Permit <br /> 1.An Engineering plan is is not required (Planning Commission Chair to circle one). <br /> 2.The Vermont Town Board approved disapproved this application <br /> (Town Chair to circle one an. • •- ow) <br /> I <br /> Si g nature: .0 : r _,_ / ! <br /> ./ <br /> L a � � Date: <br /> i) ` L7.- / I <br /> 5-/\2-/tr-7 <br /> Permit expires: Date: <br /> Note to Applicant: Driveway must be completed and receive final inspection within THREE years of Board <br /> approval date or either a permit REINSTATEMENT or a new permit will be required. <br /> Town of Vermont Driveway Permit Application Page 2 of 3 Revised 4/29/2013 <br />