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Dane County Highway and Transportation Department ACCESS PERMIT This application and permit is required and :hall be issued in accordance with the provisions of Section 53.027 of the Wisconsin Statutes and Chapter 79 of the Dane bounty Code of Ordinances. Applicant is to complete all of the following requested information(please print or type): ��/ ---7,-; E--7_5 County Trunk Highway to `s which access is requested: Name a� / -E—. C // /7'77- C-T-- Address b/eeQ/./ig0---)c.'- - R 5E ci ,....---7, State_ Zip �� �'�`" �� - /mil"// 0 1 .�� . 7i / / F-J6- k-,</�- 7�Jl Home Phone Wo k Phone FAX Existing Access?: If yes,how modified? check one): 2 Yes ❑No Relocated 0 Removed El Change of use 0 Culvert replace ❑Asphalt Paving Describe Use: 7,j�,%._1-_,l F__ /">>1 /7-/i---.7 Location(check one): cgTown 0 Village ❑City of p �///z/ s i l�/� ; Section Name of Highway and North/South/East/West side: r2(5..///7-7./ 47�r9/; T./ / Name of nearest cross road: �`—r^� ( (" Distance and direction from nearest o s road: / 10.W)1 u €.S—} -C734 J4 Existing Zoning: / �" 2/ Zoning meets intended use?: yes 0 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 ❑$100 Aericulmml Controlled Access ❑$70 Agricultural Non-Controlled Access 14$100 Residential(single family)Controlled. ccess ❑$70 Residential(single family)Non-Controlled Access ❑S200 Residential.Joint Access>1 parcel ❑$200 Commercial,<100 ADT** ❑$1,000 Private/Public.New/Existing.Street o Road ❑$500 Commercial,>100 and<1,000 ADT ❑$40 Miscellaneous ❑$1.000 Commercial,>1,000 ADT �" **.4DT denotes Average Daily 7-a(lc. Data subs antiating ADT for access or road intersections may be required. Check or money order in the amount of i� e G95 -7 payable to the Dane County Highway and Transportation Department is enclosed. Cash will only be acce.ted in person. Do not send cash in the mail. The applicant understands and agrees that the pe fitted work shall comply with all permit provisions and conditions listed on the reverse side hereof any special provisions lis -d .. low or attached hereto,and any and all plans,details or notes attached hereto and made a part thereof Property owne;„:4110ensible for notifying Dane County of any conditions and/or restrictions. ''!� j By /' - Dat %6 —/j /(7 Simla 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 Count's 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:(VC-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: ll Access granted to relocate existing s gle family home entrance onto CTH JG to this entrance onto CTH ID. Culvert may not be quired if entrance is located and graded to provide for proper drainage. Existing access on TH JG to be removed. This permit is contingent upon all other local,County and Stare agenc permits and approvals. By 4i77,t(1,n .5— 11-060 Signature of Dane Co . ,Repr entative Date By L.. -.._, - 4114,/.. ..4 a.,, a(96 —403(.0 Title Phone 0449,05.::!8A.Ni Page I oft