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APPLICATION/PERMIT FOR CONNECTION TO STATE TRUNK HIGHWAY Wisconsin Department of Transportation(WisDOT) DT1504 4/2009 s.86.07(2)Wis.Stats.&Ch.Trans 231 Wis.Adm.Code • This form is an application for permission for a STH Connection.If approved,the Document Identification Number: permit does not create a right of access or access easement for the property. Z 13-100125366-2014 • If the property has any legal restrictions that prohibit access to a state trunk highway u_ 2 (STH),WisDOT cannot approve a STH connection permit for the property. 0 Wisconsin DOT • Please type or print neatly in ink. Fill out the required information on both sides p o SW Region-Madison Office of this form per the instructions.One form is required per connection.For more of = 2101 Wright St. information,visit: y E_ ..- t )_=�ti �"`� Madison,WI 53704 • Please provide a copy of the property deed with all applications. 1.Applicant Name and Mailing Address—Street/PO Box,City,State,ZIP Code 2.Property Owner Name/Address(If not applicant) Z Frank&Dana Seltzner Robert&Deanna Sheehy z °— 4 savannah Parkway a � 971 Sand Pipper Ct. a a Deerfield,WI 53531 Sun Prairie,WI 53590 J a ar a o u. Q u- 3.If Not Property Owner,Reason for Application Purchasing Z 4.Highway Number(s) 5.County 6. ❑City ❑Village [10 Town 7.Side of the Highway a19 Dane of:Medina ❑North ®South ❑East ❑West jo 8.Located within the 9.Fire or Street Number(If applicable) o a Quarter,of the Quarter,Section 7,Town 8 North,Range 12 _ ir — (..) 0 10.Name of Nearest Side Road from Location Distance and Direction from Side Road 11.How far is the location from the w? nearest non-side road connection Z Prospector Lane 970 ft East on the same highway? 150 ft o (Feet or Alves) (N,S.E,w) U (Font or Miles) Log Mile or Reference Point(Filled in by WisDOT): RP= 040+1.08 la a. 12. Proposed Activity 13.Proposed Use(Check one—See instructions for category description) 16.Proposed Trips Per Day(Check one) (Check one) a. _ I-- o ❑Urban—Commercial/Industrial ❑Rural—Agricultural ❑Seasonal ❑ 101-1000 z P El Urban—Residential a ❑Construct New 0 Public Road ® 1-50 0 Over 1000 o o < ❑Alter Existing ❑Rural—Commercial/Industrial El Trail or Trail Crossing ❑51-100 w 0 ®Rural—Residential i e- ❑Remove Existing Is this a change of the existing use(If applicable)? ❑No Peak hour traffic count: o ®Permit Existing r>9e 9 ( PP )• ❑Yes 14.Proposed Width:20 ft 1 15.Proposed Surface:gravel QUESTIONS 17-27 on BACK PAGE All connections have restrictions,which include the information preprinted The applicant affirms that all information provided on and submitted with and filled-in on this application along with any conditions, covenants, incomplete this form is correct and con perm. denial or incorrect s supplemental provisions,superimposed incomplete inal prosecution may result n under in permit iscol si rSvocaes. as pP p perillbesed notsib and detail drawings added well as criminal rosecution under s.946.32 Wisconsin Statutes. by WisDOT. The applicant shall be responsible for complying with these p restrictions along with the construction and maintenance of the connection. `� It is further understood that WisDOT's approval is subject to applicant's full X 71444 sdepter compliance with relevant state statutes and administrative rules, plus any 10/13/2014 laws, codes, rules, regulations, ordinances and permit requirements of (Property Owner or Authorized Representative) (Date) other jurisdictional agencies.The alteration of this form by the applicant is (If Computer-filled,Brush Script Font) prohibited.Under s.86.073 Wisconsin Statutes,WisDOTs permit denial or revocation may be appealed. (Area Code and Telephone# ( P ) (E-mail address if available) FOR OFFICIAL WISDOT USE ONLY—DO NOT WRITE BELOW THIS LINE ❑THE FOLLOWING SUPPLEMENTAL PROVISIONS APPLY ® Permit APPROVED(THIS PERMIT IS REVOCABLE) El Permit DENIED ❑Application DISMISSED X J q 10/17/2014 (WisDOT Authorized Representative) (Date) (If Computer-filled,Brush Script Font) ❑Temporary permit. Expiration date: ®This permit voids/replaces permit# 11-15-03 ❑ Shared Co-user name: connection Related permit# M File: •