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Dane County Highway and Transportation Department ACCESS PERMIT This application and permit is required and shall be issued in accordance with the provisions of Section 83.027 of the Wisconsin Statutes and Chapter 79 of the Dane County Code of Ordinances. Applicant is to complete all of the following requested information(please print or type): County Trunk Highway to kI II NM GVL, L 4%1-'0 Poo L S (.■)\N •SOR- Gq1-ik'IA MS) which access is requested: C.,V Name \99.e '), lr\Glk POINT r---.niN p Address H\CI)DL'E.101\\ W\ r57)(0 62_, City State Zip 831 G5,0 8?,\ 26 5ra Home Phone Work Phone FAX Existing Access?: if yes,how modified?(check one): %Yes O No ❑Relocated ❑Removed A Change of use 0 Culvert replace D Asphalt Paving Describe Use: A(v&. t 9 S•F tZ ell l L. \ O F te. Rc3t D fc--t•' .L. b1uLIl F-AtA\L—( Location(check one): M Town 0 Village 0 City of tN\ND �pEt. Section Name of Highway and North/South/East/Westside: t‘GV li .t~ ST - Name of nearest cross road: A.pt—i.—; 1 y,i N 4t,-sLc- ge,A s Distance and direction from nearest cross road: /kGfROSS v9At-k HA?Lc SPAU\NG L{a01 C:.Ae,F),- 014(,-(to Existing Zoning: C.,..,t, Zoning meets intended use?: Yes ❑No Type of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): ❑S50 Temporary Controlled Access 0$35 Temporary Non-Controlled Access 0 550 Agricultural Controlled Access 0$35 Agricultural Non-Controlled Access c 0$50 Residential(single family)Controlled Access 0$35 Residential(single family)Non•Controlled Access itC 5100 Residential(multi family)Access l'AvAtsf)u5. 0$100 Commercial,<100 ADT** 'I\ '�U 111 S500 Private/Public,New/Existing,Street or Road O$250 Commercial,>100 and<1,000 ADT r , ill S20 Miscellaneous O$500 Commercial,>1,000 ADT 'ADT denotes Average Daily Traffic. Data substantiating ADT for access or road intersections may be required. ICheck or money order in the amount of t-20 ,payable to the Dane County Highway and Transportation Department is enclosed. Cash will only b accepted in person. Do not send cash in the mail. The applicant understands and agrees that the permitted work shall comply with all permit provisions and conditions listed on the reverse side hereof,any special provisions listed below or attached hereto,and any and all plans,details or notes attached hereto and made a part thereof. Property owner is responsible for notifying Dane County of any conditions and/or restrictions. By Date P51131131.41 Signs re of Ap icantfRepresentative NOTE: Application should be accompanied with plans or plat or CSM when appropriate. Application fee must accompany all applications..Applications to be submitted to Dane County Highway and Transportation Department,2302 Fish Hatchery Road, Madison, WI 53713. Contact the Assistant Commissioner at 266.4036 or Engineering office at 266-4037 with any questions. :, oit . • ,. , .r- , I. . • n,• /I, ....• . . . ... . I.• P.s. . It r•,-..e. .i uu., DO NOT WRITE OR TYPE BELOW THIS LINE—FOR DANE COUNTY USE ONLY PERMIT APPROVAL BY DANE COUNTY COUNTY PERMIT NUMBER: qj(-%.5 The foregoing application is hereby approved and permit issued by Dane County subject to full compliance by the Applicant with all provisions and conditions stated herein and on the reverse.slde hereof and all attachments hereto. Other Special Provisions: �� . �ccers Ce�^/mace/ i+mv,o%c/ • extstk.," ezecesse- a•-e--, • p • By •- ..(� f,��C/' • /PA s/� cL Signatu • Dane County Representative Date By l`.a7/14m/ scart.r- . _ - 02&b• 4e,- Title Phone was.uo,w Page I of 4ax.elvm'�amii•..-..