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Dane County Highway and Transportation Department <br /> ACCESS PERMIT <br /> This application and permit is required and shall be issued in accordance with the provisions of Section 83.027 of the <br /> Wisconsin Statutes and Chapter 79 of the Dane County Code of Ordinances. <br /> Applicant is to complete all of the following requested information(please print or type): <br /> County Trunk Highway to t1 1 <br /> }■l CV- L ADO PO V LA S (:t,114DSOR Go (M0k1O•which access is requested: S,V <br /> Name <br /> 1119.5 ti, 14\G4\ Pb\NI Sao <br /> Address <br /> N\0PL Q 2. <br /> City State Zip <br /> 831 G5O a31 2 G 50 <br /> Home Phone Work-Phone FAX <br /> Existing Access?: Ilya,how modified?(check one): <br /> la Yes 0 No .0 Relocated 0 Removed Change of use 0 Culvert replace 0 Asphalt Paving <br /> Describe Use: i-ki •c\ t 3 S__. - R.E-1 i i L. , t2c k Rc:Si O t 41 i M. M(,1.\t4-AtML( <br /> Location(check one): Town 0 Village 0 City of iN 1NbSAR. Section _ <br /> Name of Highway and North/South/East/West side: i C,V tl .>= S—t .. i ` • <br /> Name of nearest cross road: 1 i,y N �,1,���. p�Ad> <br /> Distance and direction from nearest cross road: i 6RQsq F1o14 MAPLE SPANN.t[s yoo i 6„at,1}I)IREG�to <br /> Existing Zoning: C..,j„ Zoning meets intended use?: Yes 0 No <br /> Type of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): <br /> 0 SSO Temporary Controlled Access 0$35 Temporary Non-Controlled Access <br /> 0 S50 Agricultural Controlled Access 0$35 Agricultural Non-Controlled Access <br /> 0 850 Residential(single family)Controlled Access 0$35 Residential(single family)Non-Controlled Access <br /> SI00 Residential(multi-family)Access VAk,ESb uSE 0$100 Commercial,<100 ADT•• <br /> ■S500 Private/Public,New/Existing,Street or Road 0 8250 Commercial,>100 and<1,000 ADT <br /> i■S20 Miscellaneous - 0 8500 Commercial,>1,000 ADT <br /> ' ADT denotes Average Dai(y Traffic. Data substantiating ADT for access or road intersections may be required. <br /> Check or money order in the amount of ,payable to the Dane County Highway and Transportation <br /> Department is enclosed. Cash will only b accepted in person. Do not send cub in the mail. <br /> The applicant understands and agrees that the permitted work shall comply with all permit provisions and conditions listed on <br /> the reverse side hereof,any special provisions listed below or attached hereto,and any and all plans,details or notes attached <br /> hereto and made thereof. Property owner is responsible for notifying Dane County of any conditions and/or restrictions. <br /> f` Date F�tci aei <br /> Signs re of Ap iant/Representative <br /> NOTE: Application should be accompanied with plans or plat or CSM when appropriate. Application fee must accompany <br /> all applications..Applications to be submitted to Dane County Highway and Transportation Department,2302 Fish Hatchery <br /> Road,Madison,Wi 53713. Contact the Assistant Commissioner at 266.4036 or Engineering office at 266-4037 with any <br /> questions. Any applicants which are denies n permit may appeal the decision to the Dane County Transportation Committee, <br /> DO NOT WRITE OR TYPE BELOW THIS LINE—FOR DANE COUNTY USE ONLY <br /> PERMIT APPROVAL BY DANE COUNTY COUNTY PERMIT NUMBER: -/.5 <br /> The foregoing application Is hereby approved and permit issued by Dane County subject to full compliance by the Applicant <br /> with all provisions and conditions stated herein and on the reverse.side hereof and all attachments hereto. <br /> Other Special Provisions: �7c<ess Cp /GucS rovno'ee1 e.c.rSf/��r ceeccsseJ et'"e" <br /> /til4 t['d0 cecoloskiv44.. <br /> • <br /> By �'.-�c �f - in��i <br /> Signatu - • •• e County Representative Date <br /> By ('.[744tH Starrr - <br /> Title Phone <br /> AIMS.t:w,v.+ Page I oft 4Wrdf ,.p.i w. las <br />