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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); N1G�4 ( �nt7(�i7�� C� ,� �W\ti1I�S0� County Trunk Highway to tl 41 Name GDih�Qt4��•which access is requested: (�v \119.5 ti• 1.1-1 G 4k Po 1t r K-.t:s k t Address cN\CDL E:701 1 \rJ\ 15"3(062_, City State Zip 831 Gc-4o 8?,\ "2-Go Home Phone Work Phone FAX Existing Access?: if yes,how modified?(check one): Yes ❑No 0 Relocated O Removed A Change of use 0 Culvert replace Ei Asphalt Paving Describe Use: m(y&L t 9 S'G- t ' G o Fib hl 1 F R�StDGtitZIAI. MuLFANtL Location(check one): ®Town ❑Village O City of w W A5d 1Z, Section Name of Highway and North/South/East/West side: 11G V tl ski--.f• ;. r• Name of nearest cross road: NkP4_' N 4tsLc- 12.0.1 Ai> Distance and direction from nearest cross road: 4 GROSS >rR1,01 1 MA?Lcc SPANW u, Liao I t N,►>r DP•V,Ito Existing Zoning: GI, Zoning meets intended use?: til Yes O No Type of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): []$50 Temporary Controlled Access O$35 Temporary Non-Controlled Access $50 Agricultural Controlled Access 0 S35 Agricultural Non-Controlled Access J$50 Residential(single family)Controlled Access O$35 Residential(single family)Non-Controlled Access I*$100 Residential(multi.family)Access ktxCD use ❑$100 Commercial,<100 ADP* S500 Private/Public,New/Existing,Street or Road O$250 Commercial,>IOU and<1,000 ADT , S20 Miscellaneous 0$500 Commercial,>1,000 ADT ''ADT denotes Average Daily Traffic, Data substantiating ADT for access or road intersections may be required. qlCheck or money order in the amount of {7(a ,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 ns � � Date 81 f j4q Sigre of Ap icant/Representative 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. :, ... • ., r- r .r . •. • 1111. II, .1/, • • "., . •- a•, • •% I.....11. ..1 nu.• DO NOT WRITE OR TYPE BELOW THIS LINE—FOR DANE COUNTY USE ONLY PERMIT APPROVAL BY DANE COUNTY COUNTY PERMIT NUMBER: qq(-1 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.side hereof and all attachments hereto. Other Special Provisions: /��7 ^0� �7ccess a.1,,�ued /,mv,o%c✓ . e.ciSf/`cl CZCCrsiet clNp.-. • c'c ..L/Kc to .L • • • dr By 'L '_c!�yY;a- /P/P- / . Signatu • Dane County Representative Date By (42/14.1n 1SStvrr-i' _ ,2 ,.4i) 9 Title Phone f49/7�0 AM Page I of t