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a <br /> • <br /> Town of Burke <br /> Driveway Permit Application <br /> (Access from private property to a town road) <br /> NAME OF APPLICANT: \APCATICI t 1 Y2 >c Di..---<-9,. <br /> ADDRESS OF APPLICANT:\i\ DE 1 (, ie, <br /> 5,An ?ca d. up) L� C <br /> PHONE NUMBER: WL - 1 ,)- 6i <br /> PROPERTY OWNER: 19111 1,\ne?e.}C <br /> LOCATION OF PROPOSED ACCESS: . <br /> Lot# t Subdivision"� 12 '' Street P_u y-. _ p-,--ca <br /> North, •outh,East,West side of ,• /' IL Road <br /> , <br /> Town of Burke,Dane County;Wisconsin <br /> / <br /> / <br /> / PERMIT CONDITIONS <br /> / (To be completed by Town Personnel) - <br /> Driveway is 24 feet wide. I request a variance of feet <br /> All culverts are to be 24 feet long. Diameter is 18 inch arch with end walls (wings). <br /> {} No drainage culvert needed <br /> { } Variance from size needed. <br /> Other Requirements: <br /> All construction equipment must use this entrance to access lot. Culverts are to be <br /> completely installed prior to final inspection and approval by highway personnel. <br /> I acknowledge rec ipt of attached Ordinance and agree to follow all terms. ; <br /> bfi ,� „X Date: / k,t <br /> P can,sign <br /> Permit grantee: tz,/ l " ef Date: <br /> 3 694 r <br /> a• 0fficiaUDesYgnee Signature) <br />