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ti <br /> • <br /> COPy <br /> Town of Vermont <br /> 4017 County Road JJ, Black Earth, WI 53515 <br /> Phone: (608) 767-2457 Fax: (608) 767-2555 <br /> Driveway Construction Permit and Inspection Application <br /> Part 1: Application: The undersigned hereby applies for a permit to construct a driveway in <br /> the Town of Vermont, Dane County, Wisconsin. <br /> The driveway will be in Section < Z. of the Town of Vermont, <br /> Entering Town or County Road or State Highway Cots✓'4-y N i g i c J COY I <br /> Through property owned by: <br /> Name of Property Owner: P on and 1 oSe l/'le.ng er <br /> 2l1Q,c . a�u1 LJ6-q / Oa"-/-a • <br /> Signature: - ' Date: /p.-/-o 7 <br /> Mailing Address: 555.O Co�A4' 1-L‘ykt.7 S 1 PA+ N ore L ) (41I <br /> Name of Applicant: Gre ckv\ { Pc.tj KP-es <br /> Signature: 4,jy_t4//Z— `likz-1 ate: /0(3 (07 <br /> Mailing Address: pj Fox F ce. -1.--c s.i <br /> M%dd LQ (-✓cr coitssn S-3 S.62 <br /> Contractor: <br /> A driveway construction plan and erosion control plan will be required for new driveway construction. <br /> Does the applicant desire to use material from the excavation of the house site to provide fill for the <br /> proposed driveway? MO . If"yes", an excavation permit must be obtained from the Town Building <br /> Inspector. <br /> Proposed driveway length in feet: 1 8 00 <br /> Application Fee (includes permit and first inspection): Driveways 100 feet and less: $300 <br /> Driveways 101 to 200 feet: $400 <br /> Driveways 201 feet and longer: $500 <br /> Application & Fee Received by: _ Date: /0"Cr- U7 <br /> Town of Vermont Driveway Permit Application Page 1 of 2 Revised 8/28/06 <br />