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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): A L' K (SO N County Trunk Highway to B Name which access is requested: /268 (16o Yfl 2 Address Atob dy E State Zip 648—a73—5132_ C008— 7Y— 55/ Home Phone Work Phone FAX Existing Access?: If yes,how modified?(check one): AYes 71N. ❑Relocated 0 Removed 0 Change of use 0 Culvert replace Describe P ❑Asphalt Paving escribe Use: Location(check one): ®Town ❑Village 0 City of C kir S T! /IA)A Section ZO Name of Highway and side: 5, to -P co Ty B Name of nearest cross road: (In"i CA Distance and direction from nearest cross road: � U F' LA,)e.5T Existing Zoning: Zoning meets intended use?: E Yes 0 No LTy a of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): $100 Temporary Controlled Access ❑$70 Temporary Non-Controlled Access ❑$100 Agricultural Controlled Access ❑$70 Agricultural Non-Controlled Access ❑$100 Residential(single family)Controlled Access 1E,$70 Residential(single family)Non-Controlled Access 0$200 Residential,Joint Access>1 parcel 0$200 Commercial,<100 AlYr ❑$1,000 Private/Public,New/Existing,Street or Road $500 Commercial,>100 and<1,000 ADT ❑$40 Miscellaneous ❑$1,000 Commercial,>1,000 ADT "ADT denotes Average Daily Traffic. Data substantiating ADT for access or road intersections may be required. Check or money order in the amount of / C) ,payable to the Dane County Department is enclosed. Cash will only be accepted in person. Do not send cash in the malty and Transportation 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 'de a.s r thereof. o er owner is responsible for notifying Dane County of any conditions and/or restrictions. By j /—y �(.O Signs.re of ApplicantRepresentative Date Z 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. Any applicants which are denied a permit may appeal the decision to the Dane County Transportation Committee. DO NOT WRITE OR TYPE BELOW THIS LINE--FOR DANE COUNTY USE ONLY PERMIT APPROVAL BY DANE COUNTY COUNTY PERMIT NUMBER: 0611-06( 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: The access shall be located 480 feet vea`s[=of the centerline of Utica Rd. Install an(15 inch x 21 inch)x 30 foot or 18 inch x 30 foot corrugated metal pipe with end walls. Enclosed is the"Culvert Selection Chart For Rural Private and Field Entrances." Note in the cross-section, the water must drain 8 to 10 feet away from the edge of the existing shoulder. This access permit is contingent on Town Board Approval and other required Permits and Approvals. This access permit is contingent on proper zoning of this property. By a-- Signature of Dane County Representative g- Date By Title `—c ° 2C‘`16(4' Phone 04045,s:n AM Page 1 of 2 h:•�h;s•eNornn�psnoibacm..2gH•t.dce