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. 03/30/2008 19:50 6087672072 MICHAELSCERAMICSTUDI PAGE 01 <br /> ... - - - ...... I .,�� r. • <br /> j <br /> COpy <br /> Town of Vermont <br /> 4017 County Road JJ., Black Earth, WI 53515 <br /> Phone: (608) 767-2457 Fax: (608) 787.2555 <br /> Driveway Construction Permit and Inspection Application <br /> Part 1: Application: The undersigned hereby applies for a permit to construct a driveway in <br /> the Town of Vermont, Dana County, Wisconsin. <br /> The driveway will be in Section / / of the Town of Vermont, .,/ <br /> Entering Town or County Road or State Highway., AZ6 X-,; <br /> Through properly owned by: _ <br /> Name of Property Owner: �L%11�c� <br /> Signature: 2 '..y`-, .. ,' Data -. 'Y 2J-`i — <br /> Mailing Address: 4".. . I ' Oc S,33-7 7 <br /> Name of Applicant: /,�w� <br /> Signature: 7/',/ -,47.49 0, Date: `r- Z2 Q� <br /> Melling Address; • 6 e / ), , v<. /Qo( <br /> 4fr ,you-,66/ 6-,1= ,S2S7 <br /> Contractor: (,'6l der 4/( <br /> A driveway conetruction plan and erosion control plan wIll be required for new driveway construction. <br /> Does the applicant desire to use material from the excavation o`the house site to provide fill for the <br /> proposed driveway? Au . If"yes", an excavation permit must be obtained from the Town Building <br /> Inspector. <br /> Proposed driveway length in feet: 2 00 ,C1 <br /> Application Fee (Includes permit and first inspection): Driveways 100 feet and less: $300 <br /> Driveways 101 to 200 feat:$400 <br /> Driveways 201 feet end longer: $500 <br /> Application &Fee Received by: < �'"�' Date: -7' -o4 <br /> Town d Vernwr%Drtwrwey Pe rn t Appteatlon Page 1 of 2 Revised 0(28Ae <br />