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, <br /> Town of Burke <br /> Driveway Permit Application <br /> (Access from private property to a town road) <br /> NAME OF APPLICANT: /.(e.,U I.Y1. /,`A cii k a Q h ST <br /> ADDRESS OF APPLICANT: /Y' 3 P e 6 it_ a r 0 0 k r✓ <br /> s v ra ,v,:e, W , 5?S 9 9 <br /> PHONE NUMBER: (,c?ic — 9 p S D.-- <br /> PROPERTY OWNER: ,70. PI-CS 1- a eTSy cJ 0 /f _, <br /> LOCATION OF PROPOSED ACCESS: <br /> Lot# 2 3 Subdivision G /G.-A trk"ES fin c 11 Street Avo/i l S 1°G SS <br /> North, South East West side of f vari- 3 f c s5 Road <br /> y <br /> Town of Burke, Dane County, Wisconsin <br /> . * * * * * * * * * * * * * * * * * * * * * * * * * <br /> PERMIT CONDITIONS <br /> (To be completed by Town Personnel) <br /> Driveway is 24 feet wide. I request a variance of feet <br /> All culverts are to .- 24 feet lon.,. Diameter ' 18 inch a ch with enc walls (wings). <br /> { } No drainage culvert needed <br /> { } Variance from size needed. <br /> Other Requirements: <br /> All construction equipment must use this entrance to access lot. Culverts are to be <br /> completely installed prior to final inspection and approval by highway personnel. <br /> I acknowledge receipt of attached 0 inance and agree to follow all terms. <br /> / C -- Date: / 2-���y <br /> Applicant signature / <br /> Permit granted: �'►�-C Date: to/z e j z >P <br /> v Official/Desi ee Signature) <br />