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� u1L - <br /> l)Ri l;A1AY CONN'FRL (•FION PERMIT AI'1'i.l( .1I ION <br /> TOWN Of lih:klll' DANK' COUNTY, WISCONSIN <br /> Applicant: Name• f! Wrio ' / ' f ��ui-'• 1 t(- <br /> Current \lailing Address: 2 2. 1.-) N ��,1 ;�� s ) f- <br /> City, Stale. /.II { <br /> Phone Number / 7 ' �S .� ?G <br /> , �-.? � '�/ - � I:rtrul. ;,/si u ' •' , t) � / ) <br /> Spec:ilicSite I.Jcation ' Nearby <br /> Roads: )('Gt. <br /> Parcel N: J , Gib 7t✓r <br /> My signature below indicates that: <br /> I have received a cop} of the I)me‘cas t hrchnance and the Applications (wide. and that <br /> I have attached the inli�rnou ton a• requested for driveway permits in Section A(2) in the Driveway <br /> Permit section of the Applications (nnde. and that <br /> I agree to construct the driveway in accordance with I osn of Rea,' Dri\e\\av Permit Ordinance 301 I <br /> and to follow the plans and other documents as approved by the town hoard which heconte part of this permit. <br /> and that <br /> have paid the application tee of` 3 to the town Clerkfl reastuer, and that <br /> I hereby give permission to the "low n Board and or their representative which could he the Plan <br /> Commission or other inspector authorized by the town hoard to enter the property in order to evaluate the site of <br /> the proposed driveway and to verily compliance with and/or to cnlorce the Driveway Ordinance. <br /> Application Signature:__ �' �- Date: Gl ' / <br /> Board decision: Approve ✓ Deny - - Date 1 11 ./ f�, <br /> Culvert required in right-of-way Yes / No HiL_pe nC-ei'.nq PI«ic <br /> Fnguteering Plan rei aired'' JJ J <br /> 1 Acs <br /> Additional Requirements? Ye, It )e.s see attached requirements No ,/ <br /> Driveway construction must begin b) Date I D 11 -- 1 1 <br /> Driveway Permit expiration Date I 17 / I <br /> \mount of cash hot d required: S Any cash humid required must he provided to the l ucc n <br /> I i I,'I reasurer bete • the er tit is issue( <br /> { <br /> t'hair Signature: 0 •/ ______� 0 <br /> Date 1 / <br /> Permit issued hr: ( lurk Si nature 62„,„&_:... nC Date 7 / I <br /> Permit is not valid unless siumed_b) the Applicant, Town Chair and Town Clerk <br /> Final inspection approval hv. Signature Datc <br /> :min lI I'd rc•nnrnct.l with interest S <br /> Original Copy —Office Files ('op■ - Applicant <br />