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• APPLICATION/PERMIT TO CONSTRUCT DRIVEWAY Wisconsin Department of Transportation 'TO STATE TRUNK HIGHWAY — EM404 196 s.86.07(2) Wis. Stats. & Ch. HY31 Wis. Adm. Code Please fill out the required information on BOTH SIDES of this form and submit to the District Office per the attached instructions. PLEASE PRINT OR TYPE. 1 DRIVEWAY LOCATION INFORMATION 1 1. Applicant Name 5. Area Code-Telephone Number 6. Highway Number 7. County LgU+z_phk'r-I, ,,(,.d)c, 11 Lo; —c137-5Sl4 7s is) •/}11//r.r:io _ 0•;/1� 2. Applicant Mailing Address 1 37 k y LA.? 7YN) rh-4-• Fizer `i) (-'= '• `:)30 C. 6. ® Town 5'`.•P ❑ Village ❑ City /-7/J /On''eL71 l✓/ .S'33-� Of: a/peo Driveway 7 9. What Type of Driveway(check one) - c� Cr New Driveway 1 Property Owner Name,If Not Applicant ❑ Improve Existing Driveway .5c An` _ ❑ Relocate Existing Driveway 4. If Not Property Owner,Reason for Application? 10. Driveway Located Within The: p/c.0 Quarter of the a_Quarter Section I t //Township North, Range tO East/West Log Mile or Reference Point: (filled in by WisDOT) V&`!�Q _ 11. Completion Date:*S U''✓ /999 12. What type of use will the driveway serve? (check one) ❑ Rural - Commercial/Industrial ❑ Urban - Commercial/Industrial \....=1 B Rural - Residential ❑ Urban - Residential / ❑ Rural - Farming MARC 13. Approximately how many times will vehicles use this driveway daily? (check one) APPROVAL go -- 100 ❑ 101 - 500 ❑ Over 500 14. What side of the highway is the proposed driveway located? (check one) FiiES ❑ North ❑ South ❑ East El-West Is 2)=1. GPhe proposed driveway less than e 500 0 feet from another driveway�on the same highway? {Q.Yes ❑ No m ,O.;.,3='f r .:q i ,.J r., c..- 3 6t,�...e(z b ) )-, 16. What is the name of the nearest side road from the pcoposed driveway? �., ��; c o c-4 ,='j"�! (-HI I t3 I ,\4-e') -C "Mk ill 44-‘ 78 a-1n cat a�c�t 4 / k-L ) u'c d �va1,'So'r' /o00 -P+ �c� C 4 4 1 o-F p 0 Qcr d dfr)jLC <a� 17. Approximately, how far is the proposed driveway from the side road listed in 16 /c''r'-'/ (di ance can be measured in feet or miles) and in what direction is the proposed driveway from the side road? (circle one orth South West East • If the driveway is not completed by the "Completion Date" specified, a time extension must be obtained from the Department or this permit is null and void and the driveway shall not be constructed unless authorized through a subsequent permit. The construction and maintenance of the driveway shall be the responsibility of the applican,t. It is understood and agreed that approval is subject to the applicant's full compliance with the pertinent Statutes, as well as any codes, rules, regulations, and permit requirements of other state and local jurisdictional agencies. The applicant shall also comply with all permit provisions, superimposed notes, and detail drawings, which may be added by the Department. Any alteration of this form by the applicant is prohibited and may be cause to revoke this permit. x �.. v, 3 —/0 —7t (Property Own /Authoriz± 7- senSignature) (Date) PERMIT Approve y Divi • of Highways Permit Number x 2./.2:1:443 1 - 4, 6)-- 9� 1 IDS tr t Director or Approved Rep eentativel (Date)