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Dane County Highway and Transportation Department ACCESS PERMIT OCT 1 4 2004 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): County Trunk Highway to 41Zi°+�-� �� /�— [/1_l �Lt-H which access is requested: AB Name I/O4 Gov_ 5 /&) Address Niq Pr-0 1-6(nki \ALE- 1A/ 33119V City A-3 State Zip lead- '5z5-N76 64.-D4,3 Home Phone Work Phone FAX Existing Access?: If yes,how modified?(check one): ®Yes ❑No rgi Relocated El Removed ❑ Change of use ❑Culvert replace ❑ Asphalt Paving Describe Use: tV einfiYp vi CA. L) \t be_ G e ,,O rrs p d dhtketii Location(check one): ®Town ❑Village ❑City of Blooming Grove Section 13 Name of Highway and North/South/East/West side: Southeasterly side of AB Name of nearest cross road: Linderdahi Drive Distance and direction from nearest cross road: About 0.5 miles southeast Existing Zoning: pt67 1 exe.05,0 /l1 - e.Ui F Zoning meets intended use?: Yes ❑No Type of Permit Requested(refer to reverse side for explanation of controlled and non-controlled access): ❑$100 Temporary Controlled Access ❑ $70 Temporary Non-Controlled Access El $100 Agricultural Controlled Access ❑ $70 Agricultural Non-Controlled Access ❑$100 Residential(single family)Controlled Access ❑$70 Residential(single family)Non-Controlled Access ❑ $200 Residential,Joint Access>1 parcel ® $200 Commercial,<100 ADT** ❑$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 ex9 ,©�,payable to the Dane County Highway and Transportation Department is enclosed. Cash will only be accepted in person. Do not send cash in the mail. 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 made a part thereof. Property owner is responsible for notifying Dane County of any conditions and/or restrictions. By a J2vs r,sy Date 1e0/0`� Signature of Applicant/Representative 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:' ?3 1 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: Access granted to serve Grace Evangelical Church. Access to be constructed as per approved plan. Existing access or +6...g_ south property lines shall be removed upon completion of the new access. Prior to construction,contact Dan Behrend at 266-4014. Inspection and approval of the construction is required. This permit is contingent upon all other local,county and state agency approvals. By ib 4 / . / Signature of D, ounty 'epr lalive Date By . . ice/. id/L% c?Co/D_410 'tie Phone 12/17,2003,12:07 PM Page 1 of 2 c:dxtanents and sacityys,gma3uacat swings tanporaty unmet files b1k6971u xa.2004.1.doc